Modification Request Form for Employees: Pregnancy or Pregnancy Related Medical Conditions

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

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

Name Name First Last
Title/Position
EIU Email
Phone Phone - ### - ### ####
Department
Supervisor's Name
Supervisor's Title
Supervisor's Email
Please describe the modification you are requesting related to pregnancy or pregnancy related medical condition. Please note the request will not automatically be granted. It will be considered and discussed during the review process.