Sample request for a change at work
A printable from Pregnancy and Pumping at Work. Fill it in by hand. Nothing you write is collected by this website.
Sample request for a change at work
Date: ______________ To: ______________ (supervisor or HR)
I am writing to ask for a change at work because of my pregnancy / recent childbirth / breastfeeding (circle one).
The change I am asking for: ______________ Starting on: ______________ For about how long: ______________
A note from my health care provider is attached (if needed).
I want to keep doing my job well. I am open to talking about other changes that would also work. Please reply in writing by ______________.
Thank you, Name: ______________ Phone: ______________
Keep a copy. Write down who you gave it to and when.
From Pregnancy and Pumping at Work. Facts checked October 21, 2026. Free information, not legal or medical advice.