Pregnancy or Pregnancy Related Modification Request Form for Students

Pregnancy or Pregnancy Related Modification Request For for Students

UBTech is committed to nondiscrimination and equal opportunity for all individuals. This form is to be used by UBTech students who are seeking reasonable academic modification due to pregnancy or pregnancy-related conditions. After you complete your submission, you will be contacted by the Title IX Coordinator. If you have any questions or concerns, please contact title9@ubtech.edu or 435-722-6932.
Full Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Program Enrolled In*

Pregnancy Modification Information
Please provide an explanation of the medical condition and the need for the reasonable modification(s)*
Identify 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 legnth of the modification(s) if known:
Start Date*

MonthDayYear
Length of Time*

Additional Information and Supplemental Documents
In some cases, UBTech will need to obtain additional information and/or documentation about your condition. This may include documenation from your doctor or other medical provider.

PLEASE ATTACH ALL MEDICAL DOCUMENTS CONNECTED WITH THIS REQUEST.
File Upload

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Please provide the course name(s) and instructor's name for each course for which you are seeking a modification: *
Should be Empty:

Pregnancy or Pregnancy Related Modification Request For for Students