{"id":1011,"date":"2024-05-22T15:57:28","date_gmt":"2024-05-22T15:57:28","guid":{"rendered":"https:\/\/www.marshall.edu\/titleix\/?page_id=1011"},"modified":"2024-05-22T15:59:47","modified_gmt":"2024-05-22T15:59:47","slug":"supportive-measures-checklist","status":"publish","type":"page","link":"https:\/\/www.marshall.edu\/titleix\/supportive-measures-checklist\/","title":{"rendered":""},"content":{"rendered":"<script type=\"text\/javascript\">\n\/* <![CDATA[ *\/\nvar gform;gform||(document.addEventListener(\"gform_main_scripts_loaded\",function(){gform.scriptsLoaded=!0}),document.addEventListener(\"gform\/theme\/scripts_loaded\",function(){gform.themeScriptsLoaded=!0}),window.addEventListener(\"DOMContentLoaded\",function(){gform.domLoaded=!0}),gform={domLoaded:!1,scriptsLoaded:!1,themeScriptsLoaded:!1,isFormEditor:()=>\"function\"==typeof InitializeEditor,callIfLoaded:function(o){return!(!gform.domLoaded||!gform.scriptsLoaded||!gform.themeScriptsLoaded&&!gform.isFormEditor()||(gform.isFormEditor()&&console.warn(\"The use of gform.initializeOnLoaded() is deprecated in the form editor context and will be removed in Gravity Forms 3.1.\"),o(),0))},initializeOnLoaded:function(o){gform.callIfLoaded(o)||(document.addEventListener(\"gform_main_scripts_loaded\",()=>{gform.scriptsLoaded=!0,gform.callIfLoaded(o)}),document.addEventListener(\"gform\/theme\/scripts_loaded\",()=>{gform.themeScriptsLoaded=!0,gform.callIfLoaded(o)}),window.addEventListener(\"DOMContentLoaded\",()=>{gform.domLoaded=!0,gform.callIfLoaded(o)}))},hooks:{action:{},filter:{}},addAction:function(o,r,e,t){gform.addHook(\"action\",o,r,e,t)},addFilter:function(o,r,e,t){gform.addHook(\"filter\",o,r,e,t)},doAction:function(o){gform.doHook(\"action\",o,arguments)},applyFilters:function(o){return gform.doHook(\"filter\",o,arguments)},removeAction:function(o,r){gform.removeHook(\"action\",o,r)},removeFilter:function(o,r,e){gform.removeHook(\"filter\",o,r,e)},addHook:function(o,r,e,t,n){null==gform.hooks[o][r]&&(gform.hooks[o][r]=[]);var d=gform.hooks[o][r];null==n&&(n=r+\"_\"+d.length),gform.hooks[o][r].push({tag:n,callable:e,priority:t=null==t?10:t})},doHook:function(r,o,e){var t;if(e=Array.prototype.slice.call(e,1),null!=gform.hooks[r][o]&&((o=gform.hooks[r][o]).sort(function(o,r){return o.priority-r.priority}),o.forEach(function(o){\"function\"!=typeof(t=o.callable)&&(t=window[t]),\"action\"==r?t.apply(null,e):e[0]=t.apply(null,e)})),\"filter\"==r)return e[0]},removeHook:function(o,r,t,n){var e;null!=gform.hooks[o][r]&&(e=(e=gform.hooks[o][r]).filter(function(o,r,e){return!!(null!=n&&n!=o.tag||null!=t&&t!=o.priority)}),gform.hooks[o][r]=e)}});\n\/* ]]> *\/\n<\/script>\n\n                <div class='gf_browser_gecko gform_wrapper gravity-theme gform-theme--no-framework' data-form-theme='gravity-theme' data-form-index='0' id='gform_wrapper_6' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Non-Academic Supportive Measure(s) Checklist<\/h2>\n                            <p class='gform_description'><\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_6'  action='\/titleix\/wp-json\/wp\/v2\/pages\/1011' data-formid='6' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_6' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_6_52\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\"><\/h3><div class='gsection_description' id='gfield_description_6_52'>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. <\/div><\/div><div id=\"field_6_7\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Information about You<\/h3><\/div><fieldset id=\"field_6_1\" class=\"gfield gfield--type-name gfield--input-type-name gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container--name no_prefix has_first_name no_middle_name has_last_name no_suffix gf_name_has_2 ginput_container_name gform-grid-row' id='input_6_1'>\n                            \n                            <span id='input_6_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_6_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_6_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_6_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_6_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_6_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_6_18\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_6_18'>Student ID Number<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_18' id='input_6_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_18\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_6_18'>Provide your 901\/903 Number<\/div><\/div><div id=\"field_6_19\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_6_19'>Preferred Name<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_19' id='input_6_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_6_19'>List your preferred name and pronouns.<\/div><\/div><div id=\"field_6_70\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_6_70'>Preferred Pronouns<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_text'><input name='input_70' id='input_6_70' type='text' value='' class='large'  aria-describedby=\"gfield_description_6_70\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_6_70'>List your preferred name and pronouns.<\/div><\/div><div id=\"field_6_11\" class=\"gfield gfield--type-select gfield--input-type-select field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_11'>Preferred Method of Contact<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_6_11' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Email' >Email<\/option><option value='Phone' >Phone<\/option><\/select><\/div><\/div><fieldset id=\"field_6_2\" class=\"gfield gfield--type-email gfield--input-type-email gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Your Email Address<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_complex ginput_container ginput_container_email gform-grid-row' id='input_6_2_container'>\n                                <span id='input_6_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_6_2' class='gform-field-label gform-field-label--type-sub '>Email Address<\/label>\n                                    <input class='' type='email' name='input_2' id='input_6_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_6_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_6_2_2' class='gform-field-label gform-field-label--type-sub '>Confirm Email Address<\/label>\n                                    <input class='' type='email' name='input_2_2' id='input_6_2_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <div class='gf_clear gf_clear_complex'><\/div>\n                            <\/div><\/fieldset><div id=\"field_6_5\" class=\"gfield gfield--type-phone gfield--input-type-phone gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_6_5'>Your Phone<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_phone'><input name='input_5' id='input_6_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><fieldset id=\"field_6_61\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >Select the below Non-Academic Supportive Measure(s) that you are requesting:<\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_61'><div class='gchoice gchoice_6_61_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.1' type='checkbox'  value='Marshall Counseling Center Referral'  id='choice_6_61_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_1' id='label_6_61_1' class='gform-field-label gform-field-label--type-inline'>Marshall Counseling Center Referral<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.2' type='checkbox'  value='Extensions of deadlines and Other Course-Related Adjustments'  id='choice_6_61_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_2' id='label_6_61_2' class='gform-field-label gform-field-label--type-inline'>Extensions of deadlines and Other Course-Related Adjustments<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.3' type='checkbox'  value='Campus Escort Services'  id='choice_6_61_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_3' id='label_6_61_3' class='gform-field-label gform-field-label--type-inline'>Campus Escort Services<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.4' type='checkbox'  value='Increased Security and Monitoring of Certain Areas of the Campus'  id='choice_6_61_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_4' id='label_6_61_4' class='gform-field-label gform-field-label--type-inline'>Increased Security and Monitoring of Certain Areas of the Campus<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.5' type='checkbox'  value='Restrictions on Contact Applied to One or More Parties'  id='choice_6_61_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_5' id='label_6_61_5' class='gform-field-label gform-field-label--type-inline'>Restrictions on Contact Applied to One or More Parties<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.6' type='checkbox'  value='Leaves of Absences'  id='choice_6_61_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_6' id='label_6_61_6' class='gform-field-label gform-field-label--type-inline'>Leaves of Absences<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_7'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.7' type='checkbox'  value='Changes in Class, Work, Housing, or Extracurricular or Any Other Activity'  id='choice_6_61_7'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_7' id='label_6_61_7' class='gform-field-label gform-field-label--type-inline'>Changes in Class, Work, Housing, or Extracurricular or Any Other Activity<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_8'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.8' type='checkbox'  value='Off-Campus Counseling\/Mental Health Information'  id='choice_6_61_8'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_8' id='label_6_61_8' class='gform-field-label gform-field-label--type-inline'>Off-Campus Counseling\/Mental Health Information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_9'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.9' type='checkbox'  value='Housing Accommodation'  id='choice_6_61_9'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_9' id='label_6_61_9' class='gform-field-label gform-field-label--type-inline'>Housing Accommodation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_11'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.11' type='checkbox'  value='Campus-Based Employment Accommodation'  id='choice_6_61_11'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_11' id='label_6_61_11' class='gform-field-label gform-field-label--type-inline'>Campus-Based Employment Accommodation<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_12'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.12' type='checkbox'  value='Support Group Information'  id='choice_6_61_12'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_12' id='label_6_61_12' class='gform-field-label gform-field-label--type-inline'>Support Group Information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_13'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.13' type='checkbox'  value='Community Advocacy Information'  id='choice_6_61_13'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_13' id='label_6_61_13' class='gform-field-label gform-field-label--type-inline'>Community Advocacy Information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_14'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.14' type='checkbox'  value='Stalking Kit'  id='choice_6_61_14'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_14' id='label_6_61_14' class='gform-field-label gform-field-label--type-inline'>Stalking Kit<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_15'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.15' type='checkbox'  value='Transportation Information'  id='choice_6_61_15'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_15' id='label_6_61_15' class='gform-field-label gform-field-label--type-inline'>Transportation Information<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_16'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.16' type='checkbox'  value='Tutoring Resources'  id='choice_6_61_16'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_16' id='label_6_61_16' class='gform-field-label gform-field-label--type-inline'>Tutoring Resources<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_17'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.17' type='checkbox'  value='Resources on Basic Needs Assistance (e.g., food, personal hygiene items, etc.)'  id='choice_6_61_17'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_17' id='label_6_61_17' class='gform-field-label gform-field-label--type-inline'>Resources on Basic Needs Assistance (e.g., food, personal hygiene items, etc.)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_61_18'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_61.18' type='checkbox'  value='Training and Education Programs Related to Sex-Based Harassment'  id='choice_6_61_18'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_61_18' id='label_6_61_18' class='gform-field-label gform-field-label--type-inline'>Training and Education Programs Related to Sex-Based Harassment<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><fieldset id=\"field_6_62\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If you selected Support Group Information above, please indicate the subject area of interest below:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' id='input_6_62'><div class='gchoice gchoice_6_62_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.1' type='checkbox'  value='Domestic Violence'  id='choice_6_62_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_1' id='label_6_62_1' class='gform-field-label gform-field-label--type-inline'>Domestic Violence<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_62_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.2' type='checkbox'  value='Sexual Assault Survivor Group'  id='choice_6_62_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_2' id='label_6_62_2' class='gform-field-label gform-field-label--type-inline'>Sexual Assault Survivor Group<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_62_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.3' type='checkbox'  value='Grief Support'  id='choice_6_62_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_3' id='label_6_62_3' class='gform-field-label gform-field-label--type-inline'>Grief Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_62_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.4' type='checkbox'  value='Cancer Support'  id='choice_6_62_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_4' id='label_6_62_4' class='gform-field-label gform-field-label--type-inline'>Cancer Support<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_62_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.5' type='checkbox'  value='Other'  id='choice_6_62_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_5' id='label_6_62_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_6_62_6'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_62.6' type='checkbox'  value='Not Applicable'  id='choice_6_62_6'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_6_62_6' id='label_6_62_6' class='gform-field-label gform-field-label--type-inline'>Not Applicable<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_6_63\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible text-input\"  data-field-class=\"text-input\" ><label class='gfield_label gform-field-label' for='input_6_63'>If you listed other above for Support Group Information, please indicate below your request:<\/label><div class='ginput_container ginput_container_text'><input name='input_63' id='input_6_63' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><fieldset id=\"field_6_64\" class=\"gfield gfield--type-checkbox gfield--type-choice gfield--input-type-checkbox gfield--width-full gfield_contains_required field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><legend class='gfield_label gform-field-label gfield_label_before_complex' >If you selected Community Advocacy Information above, please indicate the subject area of interest below:<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_checkbox'><div class='gfield_checkbox ' 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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.<\/label><input type='hidden' name='input_48.2' value='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.' class='gform_hidden' \/><input type='hidden' name='input_48.3' value='4' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_6_51\" class=\"gfield gfield--type-section gfield--input-type-section gsection field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><h3 class=\"gsection_title\">Thank you for taking the time to fill out the Non-Academic Supportive Measure(s) Checklist. 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