Pregnancy Modification Request Form for Students
The University of Utah is committed to nondiscrimination, diversity and inclusiveness of all individuals. This form is to be used by University students who are seeking reasonable academic modification due to pregnancy or pregnancy-related conditions
A
downloadable version
of the form is available.
After you complete your submission, you will recieve a response and updates from the Office of Equal Opportunity and Affirmative Action (OEO/AA) as your request is processed by the assigned staff member. If you have questions or concerns, please contact oeo@utah.edu or 801-581-8365
Contact Information
Name
uNID
Email
Phone
Student Type
Please select...
Under Graduate Student
Graduate Student
Other
Pregnancy Modification Information
Please provide a brief explanation of the medical condition and the need for the reasonable modification(s)
.
I
dentify the specific modification(s) you are requesting:
(e.g., additional breaks during class, rescheduling tests or exams, excusing absences due to pregnancy or related conditions, larger desk, etc)
Please indicate the date the modification(s) will become medically necessary and the length of the modification(s) i
f known:
Start Date
Length of Time
Enter a number for length of time, then select days/weeks/months for dropdown to the right.
x
Days/Weeks/Month
Please select...
Days
Weeks
Months
Additional Information and Supplemental Documents
In some cases, the University of Utah will need to obtain additional information and/or documentation about your condition. This may include documentation from your doctor or other medical provider
PLEASE ATTACH ALL MEDICAL DOCUMENTATION CONNECTED WITH THIS REQUEST
Students: please provide the course name, course number, and instructor's name for each course for which you are seeking a modification: