Pregnant/Parenting Student Intake & Verification Form

Background Information

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Anticipated Delivery Date(Required):

This field is required.

Student Information

Please provide the following contact information. If you are completing this form for a partner/spouse who is unable to do so, please provide their information. Please ensure you use your USF ID number.

Name

ID Number

Phone number

Email address

Healthcare Needs

Please describe the nature of your situation. This may include concerns related to classes, medical needs affecting your ability to get school work completed, anticipated scheduling conflicts, etc.(Required) This field is required.

Are you experiencing any complications or medical conditions related to the pregnancy and/or childbirth? Students with complex pregnancy or postpartum experience or comorbid conditions can also register with Student Disability Services at https://myusf.usfca.edu/sds. If so, please explain. This field is required.

What kind of academic and/or non-academic accommodations do you think will be most helpful to you? This field is required.

Who is your program director/clinical director/department chair?(Required) This field is required.

Any further information that would be helpful for the Title IX Office to know at this time? You can always share further information later. This field is required.

Medical Verification

If you have documentation from your healthcare provider, please upload that here. You can also email the Title IX Coordinator directly if you do not have it at this time. Documentation must be on the letterhead or prescription pad of your licensed care provider and must reflect the following:

Name and signature of licensed care provider
Name of student being seen by the care provider/requester modification
Verification of pregnancy/parental status
Anticipated date of delivery (or date of procedure/termination)
Date of issuance of documentation
Medical necessity/relation to pregnancy: sufficient information to indicate why the absence, need, or limitation is both medically necessary for the student AND relates to pregnancy
Nature of absence, medical need, or functional (limitation(s): sufficient information to verify how the pregnancy or related
Nature of absence, medical need, or functional limitation(s): sufficient information to verify how the pregnancy or related condition prevents the student from fully participating in their education
Modifications requested: the nature of the modifications or accommodations being requested by the student to be able to participate in their education

5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Background Information

Student Information

Healthcare Needs

Medical Verification

Submission