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Required format:

wLuqtMfUgA7wz7Zn7eSqVDk46BRxvaQVSJqH7cuL58ERvGBfFVkCBSWDdsazfHfUqCKkkmUxjA8MJDU

Title IX Pregnancy/Parenting Accommodation Request Form

OIEA's Division of Title IX is responsible for evaluating a student’s request for an accommodation related to pregnancy/parenting status.

This form should be completed when an individual is seeking an accommodation in the learning environment at UTSW because of parenting/pregnancy status. All information regarding an individual’s medical condition and the reasonable accommodation process is confidential and will only be disclosed on a need to know basis. All documents related to this request will be maintained and used in accordance with applicable state and federal law.

Upon receipt of this form, a representative from the Division of Title IX will respond to you soon. Please note that the response may not be immediate – in some cases, it may take up to two business days. If you are in need of more urgent assistance, please contact the Division of Title IX directly at 214-648-4343 or reach out to any Title IX Coordinator. A full list of confidential and non-confidential resources is available at UT Southwestern's Title IX website.

Please complete the survey below. Thank you!

Please select one of the following options for classification.

* must provide value

Medical School

School of Health Professionals

Graduate School of Biomedical Sciences

School of Public Health

GME

Other

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Name:
Student ID #:
Mailing Address:
Preferred Phone:
Personal E-mail:
University E-mail
Program of Study:
Program/Department Point(s) of Contact:

Please identify how your pregnancy or pregnancy-related condition limits your participation in any educational program or activity at UT Southwestern.

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Please identify the accommodation you are needing immediately. (You may check all that apply):

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Class section change (e.g. in person to online)

Opportunity to submit assignments/take exam after the due date

Opportunity to make up clinical/lab hours missed Counseling

Limited Exposure to Potentially Dangerous Substances (e.g. Lab or Clinical)

Larger or Different Table/Chair

Assistance Withdrawing from Courses

Counseling

Limited Lifting

Limited Standing

Restroom Use

Excused Tardiness

Excused Absences

Extended Leave of Absence

Lactation Room Assistance

Other

Are you currently experiencing any disabling medical condition(s) related to your pregnancy that would warrant accommodations?

* must provide value

Yes

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If you are seeking an accommodation based on medical advice, please provide documentation from your medical provider. *Please note, medical documentation indicating diagnosis and limitations will be required.

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Please describe any specific accommodation(s) being requested by your medical provider:

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Please describe the expected duration of the requested accommodation and list any additional comments here:

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I understand the appropriate reasonable accommodation will be determined by the University. I understand that adjustments that would fundamentally alter the academic objectives of a course of program or that would cause an undue hardship on the University may not be granted. I understand that before accommodations are provided, I may be asked to provide current documentation from a licensed medical professional, which includes the recommended accommodation.

* must provide value

By submitting this form, I understand that I am giving UTSW permission to share the generic term for my pregnancy (or related condition), general information about how the pregnancy (or related condition) affects my academic or classroom performance, information about my learning modality, and recommendations for specific accommodations with necessary staff and faculty. I am aware that parents, family, and/or advocates will not be provided with any information regarding my registration, academic progress, etc., in accordance with Family Educational Rights and Privacy Act (FERPA).

* must provide value

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To save your responses and end the survey, click the 'End Survey' button below. If you have selected the wrong option by accident and/or wish to return to the survey, click the 'Return and Edit Response' button.

Title IX Pregnancy/Parenting Accommodation Request Form

I. Requestor Information

II. Medical Information

III. Acknowledgments and Attestations

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