Medical Verification
Medical verification of pregnancy, pregnancy-related condition(s), and/or childbirth (please check the
appropriate box below):
I have enclosed the applicable medical documents with this request.
I have NOT enclosed the applicable medical documents with this request. Please explain:
Genetic Information Nondiscrimination Act of 2009 (GINA)
The Genetic Information Nondiscrimination Act of 2009 (GINA) prohibits employers and other entities
covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that
you not provide any genetic information when responding to this request for medical information.
"Genetic Information", as defined by GINA, includes an individual's family medical history, the results of an
individual's or family member's genetic tests, the fact that an individual or an individual's family member
sought or received genetic services, and genetic information of a fetus carried by an individual or
individual's family member or an embryo lawfully held by an individual or family member receiving
assistive reproductive services.
Release of Information
I hereby certify that all statements made above are true and accurate to the best of my knowledge and belief.
I hereby authorize the release of the above information to the University of Central Florida for the purpose
of determining the pregnancy, pregnancy-related condition, and/or childbirth and the
appropriateness of the requested reasonable accommodation(s). I understand that it will be my
responsibility to obtain appropriate medical documentation at the request of OIE. I further authorize the
University of Central Florida to seek clarification of this document and any medical documentation
provided, if necessary, by contacting my physician(s) or healthcare provider(s).
Requestor’s Signature Today’s Date
** Please return this completed form to:
Office of Institutional Equity
University of Central Florida
12701 Scholarship Drive, Suite 101 (Building 81)
Orlando, Florida 32816-0030
Fax: (407) 882-9009 or Email: oie@ucf.edu
For OIE Staff Use Only
Date request received:
Date medical documentation received:
Request authorized by (sign):
Date of accommodation letter:
The University of Central Florida is an Equal Opportunity/Equal Access/Affirmative Action institution.
Last edited: 04/2021
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