Lactation Accommodation Request Form

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Employee name:  __________________________________________

Job title/department: _______________________________________

Date of request: ___________________________________________

I have read [Company Name's] lactation accommodation policy and I am requesting an
accommodation to allow for lactation breaks while at work as follows (check all that apply):

____  A private space to express breast milk.

____ Lactation breaks that run concurrently with rest breaks already provided.

               Current rest break times: _____________________________________

____ Lactation breaks in addition to already provided rest breaks.

               Additional unpaid break time needed: ___________________________

____ Other ________________________________________________________

___________________________                         ____________________________
Employee signature                                                   Date

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To be completed by the employee's supervisor and returned to the employee with a copy sent to human resources.

Supervisor name: ______________________________________________

Date received: ________________________________________________

Your request for lactation break accommodations is

               ____ Approved as requested

               ____ Approved with modifications: ___________________________

                         ____________________________________________________

               ____ Denied due to: ________________________________________

                         ____________________________________________________

_______________________                                 ___________________________
Supervisor signature                                                Date