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Pregnancy Accommodations Complaint Form
* Starred fields are mandatory in order to process your request.
1
Information About You
*
Last Name:
Required
*
First Name:
Required
Middle Name:
*
Address:
Required
*
City:
Required
*
State:
Required
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ID
IL
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IA
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MH
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OR
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*
Zip:
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*
Contact phone:
Required
Best day(s) of the week and time(s) of day to reach you by phone
*
Contact e-mail address:
Required
invalid
*
Confirm e-mail address:
Email addresses must match
*
Is this complaint about you?
No
Yes
Required
What language should we contact you in?
2
Information About the Employer
*
Employer Name:
Required
Address:
City:
State:
WA
AL
AK
AS
AZ
AR
CA
CO
CT
DE
DC
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MH
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
MP
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WV
WI
WY
Zip:
*
Name of Supervisor: First Name:
Required
*
Last Name:
Required
*
Number of Employees Who Work at this Business:
Select number of employees
7 or less
8-14
15-49
50 or more
Required
Business website:
Business Phone Number:
3
Information About this Complaint
*
Is this a pregnancy accommodation complaint? Put another way, does this complaint involve an employee’s request that an employer modify her work conditions so that she may be able to continue working while pregnant?
No
Yes
Required
*
What job does the employee who requested the accommodation perform?
Required
*
Does the employee still work for the employer?
No
Yes
Required
*
What pregnancy accommodation was requested? Select all that apply.
Required
More frequent, longer, or flexible restroom breaks
Modifying a no food or drink policy
Job restructuring, reassignment, or transfer
Part-time or modified work schedule
Acquiring or modifying equipment, devices, or an employee’s work station
Providing seating or allowing the employee to sit more frequently if her job requires her to stand
Providing assistance with manual labor and limits on lifting
Scheduling flexibility for prenatal visits
Reasonable break time to breastfeed or express breast milk and/or private location other than a bathroom to do so
Other—please describe request in detail
*
Why was the accommodation requested?
Required
*
Who was the request made to?
Required
*
Was the request made verbally, in writing, or both?
Select type of request
Verbally
In Writing
Both
Required
*
Please describe the employer’s response to the accommodation request
Required
*
What has happened since the accommodation request?
Required
4
Documents
You may upload
5 files
with a total file size limit of
20 megabytes
.
Accepted Document Types:
TXT, DOC, DOCX, XLS, XLSX, PDF
Accepted Image Types:
JPG, TIF, TIFF, PNG, JPEG
Upload Attachments:
Javascript is not enabled in your internet browser. Only one file per complaint may be uploaded if Javascript is not enabled.
5
Privacy Notice, disclaimer and signature
Some or all of the information submitted on this form may constitute a public record. By selecting YES below, I acknowledge that my complaint and attachments, once submitted, may become a public record subject to review by the Attorney General’s Office for applicable restrictions on disclosure. If you would rather submit your complaint via phone, you may do so by leaving a message at (833) 389-2427 and a staff member will return your call.
Yes
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Name:
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*
Date
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