City of Chicago
EMPLOYEE/APPLICANT/VOLUNTEER
REQUEST FOR REASONAB LE ACCOMMODATION FOR PREGNANCY ,
CHILDBIRTH, AND RELATED CONDITIONS
This form is to be completed by a City of Chicago employee, volunteer, or job applicant. If additional space is needed
to fully answer a question, please attach a separate sheet of paper. Please sign and date all pages attached to this
form. This form should only be used to request accommodations for p regnancy, childbirth, or related conditions.
If you need assistance completing this form or any part of the reasonable accommodation process, please
contact the City of Chicago Department of Human Resources at 312 -744-4224 (voice) or 312-744-5035
(TTY).
When complete, this form may be submitted to the employee’s or volunteer’s departmental Disability Liaison or to the
City of Chicago Disability Officer. Please keep a copy for your records.
Although the City of Chicago must protect the confidentiality o f medical information of its employees and applicants,
please note that medical information in this form, which is needed by the City of Chicago to carry out its obligations
under state and federal law, is not considered “protected health information” unde r the Health Insurance Portability
and Accountability Act (HIPAA) and implementing regulations.
Are you pregnant?
Yes No
Are you recovering from childbirth?
Yes No
Do you need an accommodation for a common or medical condition related to pregnancy or childbirth?
Yes No
Are you requesting a reasonable accommodation related to your pregnancy , childbirth or related conditions?
Yes No
