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PREGNANCY OR PREGNANCY RELATED CONDITION ACCOMMODATION REQUEST FORM 2026

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The document is a Pregnancy or Pregnancy Related Condition Accommodation Request Form from the University of Utah, designed for staff members seeking accommodations due to pregnancy-related limitations in their work environment. It outlines the process for submitting a request, including required contact information, details about the accommodation needed, and the potential need for supporting medical documentation. The form emphasizes the university's commitment to nondiscrimination and inclusiveness.

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Click ‘Get Form’ to open it in the editor.
Begin by filling out the 'CONTACT INFORMATION' section. Provide your name, date of request, UID, job title, department/unit, and contact details including your primary email address for HR correspondence.
In the 'ACCOMMODATION INFORMATION' section, clearly identify how your pregnancy or related condition limits your ability to perform job duties. Be specific to ensure your needs are understood.
Next, specify the requested accommodation such as light duty or additional break time. If necessary, attach any additional information on a separate sheet.
Complete the 'ADDITIONAL INFORMATION & SUPPLEMENTAL DOCUMENTS' section by indicating whether you can provide supporting documentation from a medical provider if requested.
Finally, review the certification statement and sign it to confirm that all information is accurate before submitting the form to Human Resource Management.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What counts as pregnancy-related illness?

Pregnancy related sickness is any medical condition or illness that is directly related to being pregnant, for instance morning sickness, extreme exhaustion, sciatica and pre-eclampsia.

What are the 5 common means of reasonable accommodation?

Examples of reasonable accommodations include providing interpreters, readers, or other personal assistance; modifying job duties; restructuring work sites; providing flexible work schedules or work sites (i.e. telework) and providing accessible technology or other workplace adaptive equipment.

What is an example of a pregnancy accommodation letter?

I am often fatigued and nauseous in the morning as a result of my pregnancy. I would like to switch the order in which I perform my duties, so that I perform my physical tasks (unpacking boxes) in the afternoon and my sedentary tasks (data entry) in the morning.

What are examples of reasonable accommodations for pregnancy?

Some examples of possible reasonable accommodations under the PWFA include: Additional, longer, or more flexible breaks to drink water, eat, rest, or use the restroom; Changing food or drink policies to allow for a water bottle or food;

How to fill out a Request for reasonable accommodation form?

What to Include in Your Reasonable Accommodation Letter Your name and position. The date. Information about your disability. A request for accommodation. Accommodation ideas. Medical information.

pwfa request form

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What are reasonable adjustments for pregnant employees?

If there are any risks, they have to make reasonable adjustments to remove them. This can include changing your working hours. If you work with chemicals, lead or X-rays, or in a job with a lot of lifting, it may be illegal for you to continue to work.

What is considered a reasonable accommodation for pregnancy?

The Pregnant Workers Fairness Act gives workers the right to receive reasonable accommodations, like light duty, breaks, or a stool to sit on, for pregnancy, childbirth recovery, and related medical conditions, including lactation, unless it would be an undue hardship on the employer.