Pregnancy & Parenting Accommodations Request

Student Information

Student's full name:

Student's phone number:

Student's VSU email address:

Email address must be of a valid format.

Major/Program of Study:

VSU Affiliation(Required):

This field is required.

Location(Required):

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Student Information

ID Number

Accommodation Request Information

Please answer all questions below. All supporting documents (physician's letters, prognosis statement, etc.) should be uploaded below in the Additional Information & Supplemental Documents section.

What is the anticipated birthing date?(Required) This field is required.

Identify how your pregnancy or pregnancy-related condition limits you in performing your job duties or participating in your education.(Required) This field is required.

Identify requested accommodation (e.g., light duty, telecommuting, additional break time, etc.).(Required) This field is required.

Are you providing medical verification of pregnancy, pregnancy-related condition(s), and/or childbirth from your licensed medical professional?(Required)

Yes No

You must make at least one selection.

What term(s) are accommodations being requested for?(Required) This field is required.

I hereby certify that all statements made in this request are true and accurate to the best of my knowledge and belief. I hereby authorize the release of the information to Valdosta State University 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 from your licensed medical provider at the request of VSU. I further authorize Valdosta State University to seek clarification of this document and any medical documentation provided, if necessary, by contacting my medical professional(s).(Required)

I agree I disagree

You must make at least one selection.

Additional Information & Supplemental Documents

Valdosta State University will need to obtain additional information and/or documentation about your condition from your licensed medical professional. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

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Student Information

Student Information

Accommodation Request Information

Additional Information & Supplemental Documents

Submission