Lactation Space Request Form | Equity and Access Office

Northern Arizona University has dedicated lactation spaces across campus for use by employees who are nursing parents. The Equity and Access Office will reach out to you upon receipt of this form to discuss granting you access to an appropriate space. If you are not an employee and are in need of a lactation space, please complete the form and the Equity and Access Office will follow-up with you on available options.

I. Personal Information

Name *

First Last

Asserted Pronouns

Preferred Phone *

Secondary Phone

Email *

II. Relationship to NAU

Affiliation with NAU *

Please check the role(s) relevant to your request.

Employment Status *

Full-time employee

Part-time employee

Non-employee

Other *

Please indicate relationship to NAU

III. Position Information

NAU ID Number *

001234567

College/Department

Job Title

Work Location *

Supervisor Name and Title

EAO will reach out to your supervisor or other responsible person on your behalf to inform them of the accommodation and remind them of their role in the process.

IV. Request

Begin Date *

Please tell us the first date at which you will need access to a lactation room.

End Date

Please tell us your anticipated last date for needing lactation room access.

Please Describe Your Request *

As part of your description, please include which days/times you will need access. We will do our best to accommodate your time preferences, and will work with you if any changes are needed.

Room Location Desired

We will do our best to accommodate your location preference. If you are an employee, and if there is not an available space close enough to your work site, then the EAO will work with your supervisor and building manager to find a suitable space. To view lactation locations, visit the Lactation Spaces webpage.

By submitting this form, you acknowledge that it will be submitted to the Northern Arizona University Equity and Access Office (EAO) for the purpose of beginning the interactive accommodation process regarding access to lactation spaces. Questions about this form should be directed to EAO at (928) 523-3312 or EquityandAccess@nau.edu.

Name

This field is for validation purposes and should be left unchanged.