Pregnancy Form

This form is to connect students who are pregnant or experiencing other related conditions (childbirth, lactation, termination of pregnancy, or related medical conditions/recovery therefrom) with the �� Title IX Office for the purpose of requesting accommodations.

This form is NOT to report emergencies and/or to request immediate attention. If help is needed immediately, please contact University Police, at 607-777-2222 or dial 911.

We encourage you to use this form to help the Title IX Office understand the context and needs of your individual situation in advance of an accommodations meeting. All reports are sent directly to the Title IX Coordinator and/or Deputy Title IX Coordinator. If you would like to meet with a representative of the office without completing this form, please reach out to us via phone or email at:

Title IX Coordinator - Andrew Baker, abaker@binghamton.edu or 607-777-2486 Deputy Title IX Coordinator - Katy Perry, cperry@binghamton.edu or 607-777-3214

Please don't fill out this input box.

Your Information

Affiliation*Please select

Please specify (if "other" was selected in the above dropdown)

Name*

Preferred Name

Phone number*

E-mail address*

Pregnant Student Information (if different from person submitting form)

Name

Preferred Name

Phone number

E-mail Address

Academic Program

Pregnancy Information

Please indicate the date the accommodations/adjustments will become necessary, and the approximate time they’ll be needed (if known):*

What do you wish to share about your individual circumstances?*

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