Non-Title IX Academic Supportive Measure(s) Request Form

Non Title IX Academic Supportive Measure(s) Request Form

Please use this form to request Academic Supportive Measure(s). REMINDER: SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING ACADEMIC SUPPORTIVE MEASURE(S) FOR. Failure to submit a separate Request Form for each course can result in delays and a request to submit a separate Request Form.

PLEAE NOTE: It is important that you maintain direct communication with your professor(s) regarding your academic situation, as our role is solely to assist in facilitating the implementation of supportive measures.

Information about You

Your Name(Required)

First Last

Student ID Number(Required)

Provide your 901/903 Number

Preferred Name / Pronouns(Required)

List your preferred name and pronouns.

Preferred Method of Contact

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Course Information

Request for Information regarding course. REMINDER: SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING ACADEMIC SUPPORTIVE MEASURE(S) FOR. Failure to submit a separate Request Form for each course can result in delays and a request to submit a separate Request Form.

Term(Required)

List semester/term of course for which you are requesting supportive measures.

Course Year(Required)

List the year of the course you are requesting supportive measures. Please note, old courses/grades cannot usually be adjusted.

Course Title(Required)

List the Full Title for the Course

Course Code(Required)

List the Course Code. Ex. ENG101.

Meets(Required)

Day(s) and Time of Course

Location(s) of Course(Required)

Primary Instructor Name(Required)

Primary Instructor Email(Required)

Secondary Instructor Name

Secondary Instructor Email

Description of Supportive Measure(s) You Are Requesting

Please describe the description/detail of the supportive measure(s) you request (i.e., assignment extensions, excused absences, etc.) Examples: 1. State the specific dates for which you need supportive measure, and if you need extensions of time to turn in the assignments, state the name of the assignment, the due date, and the proposed deadline. 2. Please provide information regarding how you would like to submit the assignment. 3. If the assignment is submitted online, does the professor need to reopen a module or online submission page to allow you to submit it? 4. If you are requesting to retake an exam, please provide the dates you are available to take the exam. 5. If you are requesting to makeup a presentation, please state when and where you would like to do the presentation. 6. If you are requesting an excused absence, list the specific dates you are requesting for excused absences. We encourage you to speak with your professors to determine the best way to provide the supportive measure.

Description/Detail of the supportive measure(s) you request(Required)

Assignment Extension(s)

Presentation Extension(s)

Test/Exam Extension(s)

Excused Absence(s)

Other

Assignment Extension(s). 1. State the specific dates you need extensions of time to turn in the assignments, state the name of the assignment, the due date, and the proposed deadline. 2. Please provide information regarding how you would like to submit the assignment. 3. If the assignment is submitted online, does the professor need to reopen a module or online submission page to allow you to submit it? 4. If you are requesting to makeup a presentation, please state when and where you would like to do the presentation. We encourage you to speak with your professors to determine the best way to provide the supportive measure. If this does not apply to you, enter N/A.(Required)

Presentation Extension(s). 1. State the specific dates you need extensions of time to submit a presentation, state the name of the presentation, the due date, and the proposed deadline. 2. Please provide information regarding how you would like to submit the presentation. 3. If the presentation is submitted online, does the professor need to reopen a module or online submission page to allow you to submit it? 4. If you are requesting to makeup a presentation, please state when and where you would like to do the presentation. We encourage you to speak with your professors to determine the best way to provide the supportive measure. If this does not apply to you, enter N/A.(Required)

Test/Exam Extension(s). 1. State the specific dates that the test/exam was held on, and state the name of the test/exam. 2. If you are requesting to retake an exam, please provide the dates you are available to take the exam. take the test. 2. Please provide information regarding how you would like to retake the test/exam. 3. If the test/exam is submitted online, does the professor need to reopen a module or online submission page to allow you to submit it? 4. If you are requesting to makeup a test/exam, please state when and where you would like to do the test/exam. We encourage you to speak with your professors to determine the best way to provide the supportive measure. If this does not apply to you, enter N/A.(Required)

Excused Absence(s). If you are requesting an excused absence, list the specific dates you are requesting for excused absences. We encourage you to speak with your professors to determine the best way to provide the supportive measure. If this does not apply to you, enter N/A.(Required)

Other. Specify what you are requesting, including the specific dates you are requesting for the other supportive measure(s) and if you extensions of time regarding the other supportive measure(s), state the name of the other supportive measure(s), the due date, and the proposed deadline. 2. Please provide information regarding how you would like to submit the other supportive measure(s). 3. If the other supportive measure(s) is submitted online, does the professor need to reopen a module or online submission page to allow you to submit it? 4. If you are requesting to retake the other supportive measure(s), please provide the dates you are available to take the other supportive measure(s). 5. If you are requesting to makeup the other supportive measure(s), please state when and where you would like to do the other supportive measure(s). We encourage you to speak with your professors to determine the best way to provide the supportive measure. If this does not apply to you, enter N/A.(Required)

Do you currently have an internship, Field Placement, or Practicum Site?(Required)

If Yes, please provide the following: Name of Placement Site, Site Supervisor Name, and Site Supervisor Email. Use N/A is this does not apply to you.(Required)

Once you register with our office, would you like us to contact your instructor(s) on your behalf?(Required)

CAPTCHA

Thank you for taking the time to fill out the Academic Supportive Measure(s) Request Form. Someone will be in touch with you shortly.

REMINDER: SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING ACADEMIC SUPPORTIVE MEASURE(S) FOR. Failure to submit a separate Request Form for each course can result in delays and a request to submit a separate Request Form. PLEAE NOTE: It is important that you maintain direct communication with your professor(s) regarding your academic situation, as our role is solely to assist in facilitating the implementation of supportive measures.