Pregnancy Accommodation Request for Employees

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The District of Columbia Protecting Pregnant Worker Fairness Act (“PPW”) requires DC employers to provide reasonable workplace accommodations for employees whose ability to perform job duties is limited because of pregnancy, childbirth, breastfeeding, or a related medical condition.

Georgetown University maintains policies on non-discrimination such as pregnancy which is a factor prohibited by law. As set forth in those policies, the University is sensitive to accommodating its current and prospective employees who might become or who are pregnant. It is the University’s practice to provide a consistent and methodical approach in addressing requests for reasonable accommodations.

The purpose of this form is to assist the University in determining whether, or to what extent, a pregnancy accommodation can be granted.

Email *

Name *

Position *

Department *

Phone

Supervisor's Name *

Supervisor's Title *

Supervisor's Email
*

Employee Status

Faculty

Staff

Student Employee

Union Employee

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Are you requesting exemption from the University's COVID-19 vaccination and/or booster requirement?

Yes

Identify the specific accommodation you are requesting :

More frequent or longer breaks

A private, non-bathroom space for expressing breast milk

Light duty or a modified work schedule

Temporary transfer to a less strenuous or hazardous position

Time off to recover from childbirth

Purchasing or modifying work equipment, such as chairs

Relocating your work area

Permitting employee to refrain from heavy lifting

Other:

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Please indicate the date the accommodation(s) will become medically necessary and the length of the accommodation, if known:

Please provide a brief explanation of the medical condition and the need for the reasonable accommodation:

State the name of your health care provider: (An employer may require certification from a health care provider indicating that the accommodation is advisable. IDEAA has created a Medical Inquiry form to engage your health care provider in the interactive process to ascertain the need for the reasonable accommodation.)

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