PREGNANCY ACCOMMODATIONS REGISTRATION FORM

PREGNANCY ACCOMMODATIONS REGISTRATION FORM
Please be advised that Saint Elizabeth University supports individuals who are pregnant or experiencing pregnancy-related conditions in the same way and under the same policies as it does for anyone with a documented temporary medical need or disability. Therefore, Saint Elizabeth University may request information from you, including, but not limited to, documentation from a medical professional, to provide the same accommodations or support services available to others with similar medical needs.

Information for Students. Title IX of the Education Amendments of 1972 protects pregnant students from discrimination based on pregnancy, childbirth, and false pregnancy or recovery from any of these conditions. Title IX provides reasonable accommodations for such cases. https://www.steu.edu/title-ix/index.html

Please complete this form as thoroughly as possible. The Title IX Coordinator will contact you once they have received the finished form. If you have any questions about this form or need help filling it out, please feel free to reach out to Dr. Joseph Ciccone, Interim Title IX Coordinator, at jciccone@steu.edu or 973-290-4383.
YOUR INFORMATION
Name

First NameLast Name
Student ID Number
SEU Email
example@example.com
Phone Number
Please enter a valid phone number.
What best describes your situation?

I am currently pregnant.I recently gave birth.Other
Which areas of campus life would you like to request accommodations for?

Classroom AccommodationsExam AccommodationsResidence Modification (for on-campus residential students only)Other
Please provide a description explaining why you are requesting the accommodations mentioned earlier.
Do you have any diagnosed disabilities or health conditions related to your pregnancy that you would like us to be aware of? If so, please explain below.
Supporting Documentation/Authorization of Release of Information
Please provide supporting documentation from the healthcare provider.

If the information submitted in response to the University’s initial request for medical documentation does not clearly explain the nature of the disability or the need for a reasonable accommodation, the University may request reasonable supplemental documentation.

I hereby authorize the following medical professional to release information requested on this form.
Signature

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Name of Medical Professional

First NameLast Name
Email of Medical Professional
example@example.com
Phone Number of Medical Professional
Please enter a valid phone number.
Should be Empty:

PREGNANCY ACCOMMODATIONS REGISTRATION FORM

YOUR INFORMATION

Supporting Documentation/Authorization of Release of Information