Non-Academic Supportive Measure(s) Checklist Please use this checklist to indicate what Non-Academic Supportive Measure(s) you may need from the Title IX Office. REMINDER: You can submit a new checklist if you should need additional non-academic supportive measure(s) at a later time. Information about YouYour Name(Required) First Last Student ID Number(Required)Provide your 901/903 NumberPreferred Name(Required)List your preferred name and pronouns.Preferred Pronouns(Required)List your preferred name and pronouns.Preferred Method of ContactEmailPhoneYour Email Address(Required) Email Address Confirm Email Address Your Phone(Required)Select the below Non-Academic Supportive Measure(s) that you are requesting: Marshall Counseling Center Referral Extensions of deadlines and Other Course-Related Adjustments Campus Escort Services Increased Security and Monitoring of Certain Areas of the Campus Restrictions on Contact Applied to One or More Parties Leaves of Absences Changes in Class, Work, Housing, or Extracurricular or Any Other Activity Off-Campus Counseling/Mental Health Information Housing Accommodation Campus-Based Employment Accommodation Support Group Information Community Advocacy Information Stalking Kit Transportation Information Tutoring Resources Resources on Basic Needs Assistance (e.g., food, personal hygiene items, etc.) Training and Education Programs Related to Sex-Based Harassment If you selected Support Group Information above, please indicate the subject area of interest below:(Required) Domestic Violence Sexual Assault Survivor Group Grief Support Cancer Support Other Not Applicable If you listed other above for Support Group Information, please indicate below your request:If you selected Community Advocacy Information above, please indicate the subject area of interest below:(Required) Domestic Violence Sexual Assault Stalking Human Trafficking Other Not Applicable If you listed other above for Community Advocacy Information, please indicate below your request:CAPTCHACertify(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 Non-Academic Supportive Measure(s) Checklist. A member of the Title IX Office will be in touch with you shortly.REMINDER: You can submit a new checklist if you should need additional non-academic supportive measure(s) at a later time. Marshall may, as appropriate, modify or terminate supportive measures at the conclusion of the grievance procedures or at the conclusion of the informal resolution or beyond that point. Marshall provides a timely opportunity for either party to seek, from an appropriate and impartial employee, modification or reversal of Marshall's decision to provide, deny, modify, or terminate supportive measures applicable to them.