Georgia Institute of Technology

Pregnant Workers Fairness Act (PWFA) Accommodation Request Form

The PWFA provides reasonable accommodations for qualified applicants or employees who have known limitations. Under the PWFA, “limitations” are physical or mental conditions related to, affected by, or arising out of pregnancy, childbirth, or related medical conditions. If you are an Institute employee with special needs that are associated with PWFA covered conditions and you believe that reasonable accommodations will assist you in the performance of your job, please complete this form and return it to the address listed at the bottom of the page.

Requestor's Information

This is a 9-digit long identification.

Unit/College*
Department in Administration & Finance*
Department in Office of the President*
Department in Office of the Provost*
Department in the Georgia Tech Research Institute*
Department in Research*
Department in Student Engagement and Well-Being*
Department in the College of Computing*
Department in the College of Design*
Department in the College of Engineering*
Department in the College of Lifetime Learning*
Department in the College of Sciences*
Department in the Ivan Allen College of Liberal Arts*
Phone
Phone

Please include days and hours.

Supervisor Information

Phone

Details for Pregnant Workers Fairness Act Accommodation Request

Please try to limit each of your responses to 1,500 characters or less, this includes spaces.

*Submitting these documents are requested but not initially required.


  • Doctor's Note/Medical Statement
  • Verification of the Birth (i.e. Birth Certificate)



You may also attach any additional information pertinent to your Pregnant Workers Fairness Act accommodation request.

Drag and drop files here or

Electronic Signature Consent

I give the Georgia Institute of Technology permission to explore coverage and reasonable accommodations under the Pregnant Workers Fairness Act. This may include speaking to appropriate Institute personnel and/or my health care professional. I understand that all information obtained during this process will be maintained and used in accordance with PWFA confidentiality requirements. I further understand that I may be required to provide appropriate documentation to support my request.

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