Lactation Accommodation Request Form

For specific information about the Lactation Accommodation procedures, please refer to the Employee Handbook or contact HR.

Name

Email Address

Title/Position

Phone Extension

Department

Office Location

Supervisor's Name

Lactations Accommodation Request Anticipated Accommodation Duration

Start Date

End Date

Will you be using your regularly scheduled break(s) and/or lunch break for lactation purposes?

- Select -YesNo

Do you need additional time beyond your regularly scheduled break(s) and/or lunch break for lactation purposes?

- Select -YesNo

Yes I will need additional time

Number of Additional Daily Breaks Requested

Estimated Length of Each Additional Daily Break

By signing below, I certify that the information on this form is accurate.

Employee Name & Date