{"id":996,"date":"2024-05-21T20:50:17","date_gmt":"2024-05-21T20:50:17","guid":{"rendered":"https:\/\/www.marshall.edu\/titleix\/?page_id=996"},"modified":"2024-05-21T20:59:24","modified_gmt":"2024-05-21T20:59:24","slug":"pregnant-and-or-parenting-students-academic-supportive-measures-request-form","status":"publish","type":"page","link":"https:\/\/www.marshall.edu\/titleix\/pregnant-and-or-parenting-students-academic-supportive-measures-request-form\/","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_5' style='display:none'>\n                        <div class='gform_heading'>\n                            <h2 class=\"gform_title\">Pregnant and Related Conditions Academic Modification Request Form<\/h2>\n                            <p class='gform_description'>Use this form to request Title IX academic modifications related to pregnancy, childbirth, postpartum recovery, lactation, or other pregnancy\u2011related medical or mental health needs. The Title IX Office will review your request, coordinate with your instructors, and ensure you receive the support necessary for equal access to your courses.\r\n(For absences only, please use the University\u2011Excused Absence process.)<\/p>\n                        <\/div><form method='post' enctype='multipart\/form-data'  id='gform_5'  action='\/titleix\/wp-json\/wp\/v2\/pages\/996' data-formid='5' novalidate>\n                        <div class='gform-body gform_body'><div id='gform_fields_5' class='gform_fields top_label form_sublabel_above description_below validation_below'><div id=\"field_5_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_5_52'>PLEASE NOTE, SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING PREGNANT AND RELATED CONDITIONS ACADEMIC MODIFICATION FORM. Failure to submit a separate Request Form for each course can result in delays and a request to submit a separate Request Form. \n\nAdditionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around modifications.<\/div><\/div><div id=\"field_5_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_5_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_5_1'>\n                            \n                            <span id='input_5_1_3_container' class='name_first gform-grid-col gform-grid-col--size-auto' >\n                                                    <label for='input_5_1_3' class='gform-field-label gform-field-label--type-sub '>First<\/label>\n                                                    <input type='text' name='input_1.3' id='input_5_1_3' value=''   aria-required='true'    autocomplete=\"given-name\" \/>\n                                                <\/span>\n                            \n                            <span id='input_5_1_6_container' class='name_last gform-grid-col gform-grid-col--size-auto' >\n                                                            <label for='input_5_1_6' class='gform-field-label gform-field-label--type-sub '>Last<\/label>\n                                                            <input type='text' name='input_1.6' id='input_5_1_6' value=''   aria-required='true'    autocomplete=\"family-name\" \/>\n                                                        <\/span>\n                            \n                        <\/div><\/fieldset><div id=\"field_5_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_5_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_5_18' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_18\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_18'>Provide your 901\/903 Number<\/div><\/div><div id=\"field_5_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_5_19'>Preferred Name \/ 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_19' id='input_5_19' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_19\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_19'>List your preferred name and pronouns.<\/div><\/div><div id=\"field_5_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_5_11'>Preferred Method of Contact<\/label><div class='ginput_container ginput_container_select'><select name='input_11' id='input_5_11' class='medium gfield_select'     aria-invalid=\"false\" ><option value='Email' >Email<\/option><option value='Phone' >Phone<\/option><\/select><\/div><\/div><fieldset id=\"field_5_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_5_2_container'>\n                                <span id='input_5_2_1_container' class='ginput_left gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_5_2' class='gform-field-label gform-field-label--type-sub '>Email Address<\/label>\n                                    <input class='' type='email' name='input_2' id='input_5_2' value=''    aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"email\"\/>\n                                <\/span>\n                                <span id='input_5_2_2_container' class='ginput_right gform-grid-col gform-grid-col--size-auto'>\n                                    <label for='input_5_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_5_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_5_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_5_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_5_5' type='tel' value='' class='medium'   aria-required=\"true\" aria-invalid=\"false\"  autocomplete=\"tel\" \/><\/div><\/div><div id=\"field_5_61\" 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\">Additional Information<\/h3><\/div><div id=\"field_5_62\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_62'>Please list your anticipated due date, child&#039;s birthdate, or general reason(s) for requesting modification(s).<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_62' id='input_5_62' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_8\" 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\">Course Information<\/h3><div class='gsection_description' id='gfield_description_5_8'>Request for Information regarding course. REMINDER: SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING PREGNANT AND RELATED CONDITIONS ACADEMIC MODIFICATION FORM. Failure to submit a separate Request Form for each course can result in delays and a request to submit a separate Request Form. \nAdditionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around modifications.<\/div><\/div><div id=\"field_5_26\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-half gfield_contains_required field_sublabel_above gfield--has-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_26'>Term<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_26' id='input_5_26' class='large gfield_select'  aria-describedby=\"gfield_description_5_26\"  aria-required=\"true\" aria-invalid=\"false\" ><option value='Fall' >Fall<\/option><option value='Spring' >Spring<\/option><option value='Summer' >Summer<\/option><\/select><\/div><div class='gfield_description' id='gfield_description_5_26'>List semester\/term of course for which you are requesting modifications.<\/div><\/div><div id=\"field_5_30\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_30'>Course Year<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_30' id='input_5_30' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_30\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_30'>List the year of the course you are requesting modifications. Please note, old courses\/grades cannot usually be adjusted. <\/div><\/div><div id=\"field_5_31\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_31'>Course Title<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_31' id='input_5_31' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_31\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_31'>List the Full Title for the Course<\/div><\/div><div id=\"field_5_28\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_28'>Course Code<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_28' id='input_5_28' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_28\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_28'>List the Course Code. Ex. ENG101.<\/div><\/div><div id=\"field_5_36\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_36'>Meets<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_36' id='input_5_36' type='text' value='' class='large'  aria-describedby=\"gfield_description_5_36\"   aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><div class='gfield_description' id='gfield_description_5_36'>Day(s) and Time of Course<\/div><\/div><div id=\"field_5_37\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required 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_5_37'>Location(s) of Course<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_37' id='input_5_37' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_32\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required 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_5_32'>Primary Instructor 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_32' id='input_5_32' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_33\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half gfield_contains_required 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_5_33'>Primary Instructor Email<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_33' id='input_5_33' type='text' value='' class='large'     aria-required=\"true\" aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_34\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_34'>Secondary Instructor Name<\/label><div class='ginput_container ginput_container_text'><input name='input_34' id='input_5_34' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_35\" class=\"gfield gfield--type-text gfield--input-type-text gfield--width-half 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_5_35'>Secondary Instructor Email<\/label><div class='ginput_container ginput_container_text'><input name='input_35' id='input_5_35' type='text' value='' class='large'      aria-invalid=\"false\"   \/><\/div><\/div><div id=\"field_5_25\" 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\">Description of Modifications You Are Requesting<\/h3><div class='gsection_description' id='gfield_description_5_25'>Please describe the description\/detail of the modifications you request (i.e., assignment extensions, excused absences, etc.)\n\n\nExamples:\n1.\tState the specific dates for which you need modification, 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 modifications.\n2.\tPlease provide information regarding how you would like to submit the assignment.\n3.\tIf the assignment is submitted online, does the professor need to reopen a module or online submission page to allow you to submit it?\n4.\tIf you are requesting to retake an exam, please provide the dates you are available to take the exam.\n5.\tIf you are requesting to makeup a presentation, please state when and where you would like to do the presentation.\n6.\tIf you are requesting an excused absence, list the specific dates you are requesting for excused\nabsences.\n\nWhile the Title IX Office is responsible for requesting the modifications, we encourage you to speak with your professors to determine the best way to provide the modifications. \nAdditionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around modifications.\n<\/div><\/div><fieldset id=\"field_5_53\" 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' >Description\/Detail of the modifications you request<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_5_53'><div class='gchoice gchoice_5_53_1'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.1' type='checkbox'  value='Assignment Extension(s)'  id='choice_5_53_1'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_53_1' id='label_5_53_1' class='gform-field-label gform-field-label--type-inline'>Assignment Extension(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_53_2'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.2' type='checkbox'  value='Presentation Extension(s)'  id='choice_5_53_2'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_53_2' id='label_5_53_2' class='gform-field-label gform-field-label--type-inline'>Presentation Extension(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_53_3'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.3' type='checkbox'  value='Test\/Exam Extension(s)'  id='choice_5_53_3'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_53_3' id='label_5_53_3' class='gform-field-label gform-field-label--type-inline'>Test\/Exam Extension(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_53_4'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.4' type='checkbox'  value='Excused Absence(s)'  id='choice_5_53_4'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_53_4' id='label_5_53_4' class='gform-field-label gform-field-label--type-inline'>Excused Absence(s)<\/label>\n\t\t\t\t\t\t\t<\/div><div class='gchoice gchoice_5_53_5'>\n\t\t\t\t\t\t\t\t<input class='gfield-choice-input' name='input_53.5' type='checkbox'  value='Other'  id='choice_5_53_5'   \/>\n\t\t\t\t\t\t\t\t<label for='choice_5_53_5' id='label_5_53_5' class='gform-field-label gform-field-label--type-inline'>Other<\/label>\n\t\t\t\t\t\t\t<\/div><\/div><\/div><\/fieldset><div id=\"field_5_54\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_54'>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 modifications, we encourage you to speak with your professors to determine the best way to provide the modifications. If this does not apply to you, enter N\/A.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_54' id='input_5_54' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_59\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_59'>Presentation 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 modifications, we encourage you to speak with your professors to determine the best way to provide the modifications. If this does not apply to you, enter N\/A.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_59' id='input_5_59' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_57\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_57'>Test\/Exam 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 modifications, we encourage you to speak with your professors to determine the best way to provide the modifications. If this does not apply to you, enter N\/A.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_57' id='input_5_57' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_58\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_58'>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 modifications, we encourage you to speak with your professors to determine the best way to provide the modifications. If this does not apply to you, enter N\/A.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_58' id='input_5_58' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_60\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_60'>Other. Specify what you are requesting, including the specific dates you are requesting for the other modifications and if you extensions of time regarding the other modifications, state the name of the other modifications, the due date, and the proposed deadline.  If this does not apply to you, enter N\/A.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_60' id='input_5_60' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_41\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full 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_5_41'>Do you currently have an internship, Field Placement, or Practicum Site?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_41' id='input_5_41' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_5_45\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_45'>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.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_45' id='input_5_45' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_63\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_63'>Please describe any additional factors impacting your education based on your pregnant and related conditions status. Use N\/A if not applicable to you.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_63' id='input_5_63' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_64\" class=\"gfield gfield--type-textarea gfield--input-type-textarea gfield--width-full 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_5_64'>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.<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_textarea'><textarea name='input_64' id='input_5_64' class='textarea large'     aria-required=\"true\" aria-invalid=\"false\"   rows='10' cols='50'><\/textarea><\/div><\/div><div id=\"field_5_65\" 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\">Additional documentation from your medical provider to verify your pregnancy, child&#039;s birth, and\/or specified circumstances may be requested at any time.<\/h3><\/div><div id=\"field_5_47\" class=\"gfield gfield--type-select gfield--input-type-select gfield--width-full 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_5_47'>Once you register with our office, would you like us to contact your instructor(s) on your behalf?<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/label><div class='ginput_container ginput_container_select'><select name='input_47' id='input_5_47' class='large gfield_select'    aria-required=\"true\" aria-invalid=\"false\" ><option value='Yes' >Yes<\/option><option value='No' >No<\/option><\/select><\/div><\/div><div id=\"field_5_49\" class=\"gfield gfield--type-captcha gfield--input-type-captcha gfield--width-full field_sublabel_above gfield--no-description field_description_below field_validation_below gfield_visibility_visible\"  ><label class='gfield_label gform-field-label' for='input_5_49'>CAPTCHA<\/label><div id='input_5_49' class='ginput_container ginput_recaptcha' data-sitekey='6LcJtEQiAAAAAP_vuQ362iVBQS2x9xrCp_cm3msg'  data-theme='light' data-tabindex='0'  data-badge=''><\/div><\/div><fieldset id=\"field_5_48\" class=\"gfield gfield--type-consent gfield--type-choice gfield--input-type-consent 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' >Certify<span class=\"gfield_required\"><span class=\"gfield_required gfield_required_text\">(Required)<\/span><\/span><\/legend><div class='ginput_container ginput_container_consent'><input name='input_48.1' id='input_5_48_1' type='checkbox' value='1'   aria-required=\"true\" aria-invalid=\"false\"   \/> <label class=\"gform-field-label gform-field-label--type-inline gfield_consent_label\" for='input_5_48_1' >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.<\/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='3' class='gform_hidden' \/><\/div><\/fieldset><div id=\"field_5_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 Pregnant and Related Conditions Academic Modification Request Form. A member of the Title IX Office will be in touch with you shortly.<\/h3><div class='gsection_description' id='gfield_description_5_51'>REMINDER: SUBMIT A SEPARATE REQUEST FORM FOR EACH COURSE YOU ARE REQUESTING PREGNANT AND RELATED CONDITIONS ACADEMIC MODIFICATION FORM. Failure to submit a separate Request Form for each course can result in delays and a request to submit a separate Request Form.  \nAdditionally, issues related to licensure, and not an institutional decision, are not waivable requirements or ones that can be subject to work-around modifications.<\/div><\/div><\/div><\/div>\n        <div class='gform-footer gform_footer top_label'> <button class=\"mx-auto inline-flex justify-center items-center space-x-2 bg-green text-white hover:text-white hover:bg-green-dark no-underline text-xl font-bold uppercase rounded-sm py-2 px-4 lg:py-3 lg:px-6 text-center transition-all duration-150 ease-in-out dark:text-gray-900 dark:hover:text-gray-900 group\"  type='submit' id='gform_submit_button_5' class='gform_button button' onclick='gform.submission.handleButtonClick(this);' data-submission-type='submit' ><span>Submit<\/span><svg xmlns=\"http:\/\/www.w3.org\/2000\/svg\" fill=\"none\" viewBox=\"0 0 24 24\" stroke-width=\"1.5\" stroke=\"currentColor\" 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