UNIVERSITY OF CENTRAL FLORIDA
Office of Institutional Equity
Pregnancy Accommodation Request Form
Policy Statement: Title IX of the Education Amendments of 1972 prohibits discrimination based on sex
in education programs or activities including academic, educational, extracurricular, athletic, and other
programs or activities of schools. UCF Policy 2.004 prohibits discrimination based on sex (including
pregnancy and parental status).
Reasonable Accommodations: Students may request reasonable accommodations necessary due to the
student's pregnancy, pregnancy-related condition, and/or childbirth. Reasonable accommodations include,
but are not limited to: providing accommodations requested by the student to protect the health and
safety of the student and/or the pregnancy; making modifications to the physical environment; providing
mobility support; extending deadlines and/or allowing the student to make up tests or assignments
missed for pregnancy-related absences; remote learning options; excusing medically-necessary absences;
granting a withdrawl per UCF's medical withdrawl policy or implementing incomplete grades for classes
that will be resumes at a future date; allowing breastfeeding students reasonable time and space to pump
breast milk in a location that is private, clean, and reasonable accessible (bathrom stalls do not meet this
requirement). A list of current designated lactations rooms can be found at:
https://hr.ucf.edu/files/Lactation-Room-Locations.pdf.
UCF is not required to modify the essential elements of any academic program or course.
Requestor Information
Student ID:
Request Date:
Name:
Last
First M.I.
UCF Affiliation:
Undergraduate
Graduate
Visiting/Non-degree
Other (please specify):
Telephone:
Email:
Major/Program of Study:
The University of Central Florida is an Equal Opportunity/Equal Access/Affirmative Action institution.
Last edited: 04/2021
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Reasonable Accommodation Request
Term of Request: Fall
Spring Summer
Courses for the Term of Request:
All courses for the term of the request
If your request is not for all courses in the term, please provide details for each course below.
Subject
Course
Number
Section
Number
Instructor
Instructor Email
Subject
Course
Number
Section
Number
Instructor
Instructor Email
Subject
Course
Number
Section
Number
Instructor
Instructor Email
Subject
Course
Number
Section
Number
Instructor
Instructor Email
Subject
Course
Number
Section
Number
Instructor
Instructor Email
Please select the reason for your request:
Excused absence due to pregnancy, pregnancy-related conditions, or childbirth: Please provide
authorized documentation signed by a physician or other medical personnel on medical facility/doctor
office letterhead. Document should state the situation/condition causing interference with class
attendance and must include dates of treatment and date when you are medically able to resume class
attendance.
Ability to make up missed exam/test due to pregnancy, pregnancy-related conditions, or
childbirth: Please provide authorized documentation signed by a physician or other medical personnel on
medical facility/doctor office letterhead. Document should state the situation/condition causing
interference with completing the exam during the scheduled date and time and must include dates of
treatment.
Accommodations due to pregnancy, pregnancy-related conditions, or childbirth: Please provide
authorized documentation signed by a physician denoting proof of pregnancy and/or childbirth.
Please select one or more requested accommodations, or select
“Other” and list the accommodation(s) requested:
Larger desk or work area
Designated nursing/lactation room
Breaks during class, as reasonably needed
Attendance flexibility due to doctor’s appointments
Distance learning due to inability to attend in-person class meetings
Other (please specify):
Page 2 of 3 The University of Central Florida is an Equal Opportunity/Equal Access/Affirmative Action institution.
Last edited: 04/2021
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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