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.

 
 
 
 
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.

Drop your files here
 

 

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.