Pregnancy Accommodations Complaint Form

* Starred fields are mandatory in order to process your request.

1 Information About You

*Last Name:

*First Name:

Middle Name:

*Address:

*City:

*State:

*Zip:

*Contact phone:

Best day(s) of the week and time(s) of day to reach you by phone

*Contact e-mail address:

*Confirm e-mail address:

*Is this complaint about you? No Yes

What language should we contact you in?

2 Information About the Employer

*Employer Name:

Address:

City:

State:

Zip:

*Name of Supervisor: First Name:

* Last Name:

*Number of Employees Who Work at this Business:

Select number of employees

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

*What job does the employee who requested the accommodation perform?

*Does the employee still work for the employer? No Yes

*Why was the accommodation requested?

*Who was the request made to?

*Was the request made verbally, in writing, or both?

Select type of request

*Please describe the employer’s response to the accommodation request

*What has happened since the accommodation request?

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:

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

*Name:

*Date

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