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Request for Pregnancy Adjustments and Accommodations for Students

Under Title IX regulations, students experiencing medically documented complications due to pregnancy are entitled to receive reasonable adjustments and accommodations to the learning environment. Adjustments are made on a case by case basis in consideration of academic requirements and documented pregnancy related medical needs. If you need an accommodation because you are either pregnant or in postpartum recovery, please complete the form below.

Student Information

Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Category of Pregnancy Status(Required):

This field is required.

Course Location(s)(Required):

This field is required.

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Classification of Course(s)

Course(s) & Section Number(s):

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List the course sections that you are including in this request. For example, ENG-111-FJT01.

Questions

Please answer the questions below to help give us more information about your educational needs.

Please select one or more of the following accommodation requests, if applicable.

Excused absences related to pregnancy or childbirth including postpartum recovery Rescheduling tests or exams due to excused absences Submitting work after a deadline due to excused absences Elevator access Larger desk Break time to use lactation room Frequent trips to the restroom

You must make at least one selection.

If your requested accommodation was not listed above and/or you want to provide more information, please use the input box below to provide additional details. This field is required.

Do you already have a doctor's note documenting appointment dates and/or recommending accommodations?(Required)

Yes No Unsure

This field is required.

Anticipated due date, if applicable This field is required.

Supporting Documentation

If available, please upload any documentation that supports the requested accommodations. Additional documentation may be requested and submitted once this form is processed by the Title IX Coordinator for Students. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Submission

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