Light Sensitivity Accommodation Request
Submit your request for adjustments or support due to light sensitivity. Please provide all relevant details to help us process your request efficiently.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Affiliation/Department (e.g., School, Workplace, Division)
*
Role or Position (e.g., Student, Employee, Visitor)
*
Please Select
Student
Employee
Faculty/Staff
Visitor
Other
Describe Your Light Sensitivity Condition (including diagnosis, if applicable)
*
What are your primary light sensitivity triggers?
*
Fluorescent lighting
LED lighting
Sunlight
Computer/phone screens
Other
Describe the symptoms you experience due to light sensitivity
*
What specific accommodations are you requesting?
*
Alternative lighting (e.g., desk lamp, natural light)
Permission to wear sunglasses or hats indoors
Flexible seating/location
Remote/online participation
Other
Have you previously received accommodations for light sensitivity?
*
Yes
No
Please upload any supporting documentation (e.g., medical note, previous accommodation letter)
Upload a File
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Preferred method of contact
Email
Phone
Date of Request
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Additional comments or information (optional)
I certify that the information provided is accurate to the best of my knowledge.
*
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