Employee Rights for Pregnant Employees

EMPLOYEE RIGHTS FOR PREGNANT EMPLOYEES

Personal Information

Position Information

Employment History (for HR record)

Education

References

Legal Disclosures and Notices

At-will employment: Employment with the employer is at-will, which means either the employee or the employer may terminate the employment relationship at any time, with or without cause or notice, except as otherwise provided by a written agreement signed by an authorized representative of the employer.

Equal opportunity: The employer does not discriminate on the basis of pregnancy, childbirth, related medical conditions, or any protected characteristic. Reasonable accommodations for pregnancy-related conditions will be considered in accordance with applicable law and employer policy.

Employee Rights — Summary of Protections

Reasonable accommodations: Employees with pregnancy-related medical conditions have the right to request reasonable accommodations, which may include modified duties, temporary transfers, additional rest breaks, adjusted schedules, or time off for medical appointments. The employer will engage in an interactive process to determine appropriate accommodations.

Leave and job protection: Where eligible under employer policy or applicable leave laws, employees may take job-protected leave for pregnancy, childbirth, and recovery. Leave may be paid, unpaid, or a combination, depending on available leave balances and applicable policies.

Lactation accommodation: Employees who choose to express breast milk are entitled to reasonable break time and a private, non-bathroom location to do so. The employer will provide a clean, private space and reasonable break time according to business needs and applicable law.

Medical certifications: The employer may require reasonable documentation from a health care provider to support a request for accommodation or leave. Medical information will be treated as confidential and maintained separately from personnel files.

Non-retaliation: The employer prohibits retaliation for requesting accommodations, taking protected leave, or asserting rights related to pregnancy or childbirth. Any adverse action that is in whole or part motivated by an employee’s request for pregnancy-related accommodation or leave may be a violation of policy.

Requesting an Accommodation or Leave

To request an accommodation or leave, notify Human Resources or your reporting manager as soon as practicable. Provide the following information to begin the interactive process: the nature of the condition, requested accommodation or leave dates, and any available medical documentation. The employer will respond promptly and may request additional information necessary to evaluate the request.

Employee Declarations and Choices

Are you currently pregnant? Yes No

Expected due date:

I request the following accommodation(s) at this time (check all that apply):

Temporary light duty

Modified schedule or reduced hours

Additional rest or restroom breaks

Time off for medical appointments

Lactation break/time and private space

Medical Authorization and Background Check Consent

Medical documentation: By requesting accommodations or leave, you authorize release of necessary medical information to the Human Resources department for the purpose of evaluating reasonable accommodations or leave eligibility. Medical information will be maintained in a confidential manner.

Authorization to contact prior employers and conduct background check: I authorize the employer to contact prior employers and to obtain background information as permitted by law.

Confidentiality and Recordkeeping

All medical records and documentation provided in connection with pregnancy-related accommodations or leave requests will be kept confidential to the extent required by law. Access is limited to individuals with a business need to know, such as Human Resources and designated managers.

Complaint Procedure

If you believe your rights under this notice have been violated, you should promptly notify Human Resources in writing. The employer will investigate and respond. Retaliation against any employee for filing a complaint or participating in an investigation is prohibited.

Applicant/Employee Certification

I certify that the information provided on this form is true and complete to the best of my knowledge. I understand my rights concerning pregnancy-related accommodations, leave, confidentiality, and non-retaliation. I authorize the employer to obtain and review medical documentation related to my request and to contact prior employers and references as indicated above.

By checking the box below I acknowledge receipt of this notice and understand my rights and responsibilities as described. I acknowledge receipt of this notice

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