University of Miami, Workplace Equity and Performance Office
Nursing Mothers Accommodation Request Form

The University is committed to and recognizes the importance of providing work-life support and workplace flexibility for nursing mothers. The Break Time for Nursing Mothers Policy provides reasonable break time for mothers to express breast milk for up to one year following the birth of a child.

To request an accommodation please complete and submit this form. A copy of this form will be forwarded to your supervisor and the Workplace Equity and Performance Office. Nursing mothers shall discuss their accommodation request with their supervisor so that appropriate accommodations can be arranged.

Required questions are marked with an (*).

* Employee Name (You must type in a response)
  Name of the employee requesting accommodation
 
 
* Employee UMID: (You must type in a response)
  Employee's UMID
 
 
Department Name (Type in a response)
 
 
* Work Phone # (You must type in a response)
 
 
Job Title (Type in a response)
  Job title of the employee requesting accommodation
 
 
* Select Employment Status: (Select only one)
 
 
* Supervisor/Department Head: (You must type in a response)
 
 
* Supervisor Email Address (You must enter a valid email address)
 
 
* Select Nursing Mothers Room Location: (Select only one)
 
 
* Include days and times that you would like to use the Nursing Mothers Room. (You must type in a response)
 
 
  Enter the calendar date you would like the accommodation to begin and end.
* Enter Begin Date Help (You must type in a response)
 
 
* Enter End Date (You must type in a response)
 
 
* Enter Child's Birth Date (You must type in a response)
 
 
   

Thank you; your Nursing Mother Accommodation Request Form has been submitted. If you have any questions regarding the Break Time for Nursing Mothers policy or your accommodation request, please contact the Workplace Equity and Performance Office at the Coral Gables campus (305) 284-3064; or the Miller School of Medicine campus: (305) 243-7203. Email inquiries may be directed to .(JavaScript must be enabled to view this email address).