- Title IX Office

Pregnant and/or Parenting Students Academic Supportive Measure(s) Request Form

PLEASE NOTE, SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING PREGNANT AND/OR PARENTING STUDENTS 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. Additionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around accommodations.

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)

Additional Information

Please list your anticipated due date, child's birthdate, or general reason(s) for requesting supportive measure(s).(Required)

Course Information

Request for Information regarding course. REMINDER: SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING PREGNANT AND/OR PARENTING STUDENTS 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. Additionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around accommodations.

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. Additionally, issues related to licensure, and not an institutional decision, are not waivable requirements or one that can be subject to work-around accommodations. 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. Additionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around accommodations.

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. 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)

Please describe any additional factors impacting your education based on your pregnant and/or parenting status. Use N/A if not applicable to you.(Required)

If you have a disability or limitation(s) (i.e., high-risk) involved in your pregnancy, please note below. Specify the limitation(s) below. Use N/A if not applicable to you. Any limitation(s) will likely result in contact with the Office of Accessibility and Accommodations to address that issue.(Required)

Additional documentation from your medical provider to verify your pregnancy, child's birth, and/or specified circumstances may be requested at any time.

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 Pregnant and/or Parenting Student 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 PREGNANT AND/OR PARENTING STUDENTS 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. Additionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around accommodations.