Modification Request Form for Students: Pregnancy or Pregnancy Related Conditions

Please complete this form to request reasonable modifications related to pregnancy or pregnancy related conditions.

Upon submitting this form, it will be reviewed by the Title IX Coordinator in the Office of Civil Rights & Diversity. The Coordinator will contact you for a follow-up discussion to gather additional information.

Name Name * First Last
Address Address *
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
EIU Email *
Phone Phone * - ### - ### ####
Please describe the modification you are requesting related to pregnancy or pregnancy related conditions. Please note the request will not automatically be granted. It will be considered and discussed during the review process. *