Academic Supportive Measure(s) Request Form Please use this form to request Academic Supportive Measure(s) from the Title IX Office. 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. Information about YouYour Name(Required) First Last Student ID Number(Required)Provide your 901/903 NumberPreferred Name / Pronouns(Required)List your preferred name and pronouns.Preferred Method of ContactEmailPhoneYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Course InformationRequest 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)FallSpringSummerList 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 CourseCourse Code(Required)List the Course Code. Ex. ENG101.Meets(Required)Day(s) and Time of CourseLocation(s) of Course(Required)Primary Instructor Name(Required)Primary Instructor Email(Required)Secondary Instructor NameSecondary Instructor EmailDescription of Supportive Measure(s) You Are RequestingPlease 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. While the Title IX Office is responsible for requesting the supportive measure, 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. While the Title IX Office is responsible for requesting the supportive measure, 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. While the Title IX Office is responsible for requesting the supportive measure, 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. While the Title IX Office is responsible for requesting the supportive measure, 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. While the Title IX Office is responsible for requesting the supportive measure, 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). While the Title IX Office is responsible for requesting the supportive measure, 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)YesNoIf 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)YesNoCAPTCHACertify(Required) I hereby certified that I am the student filling out this form, and to the best of my knowledge, the information I have provided in this request form is true.Thank you for taking the time to fill out the Academic Supportive Measure(s) Request Form. A member of the Title IX Office 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.