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
*********************************************************************************************************************
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
Advertisement
An organization run by AI is not a futuristic concept. Such technology is already a part of many workplaces and will continue to shape the labor market and HR. Here's how employers and employees can successfully manage generative AI and other AI-powered systems.
Advertisement