Accessibility Concerns Notification Form- West Lafayette Campus

Background Information

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Your full name:

Your position/title:

Your phone number:

Your email address:

Email address must be of a valid format.

Your physical address:

Nature of your concern(Required):

This field is required.

Urgency of this report(Required):

This field is required.

Date of incident(Required):

This field is required.

Time of incident:

Location of incident(Required):

This field is required.

Location of Accessibility Concern

Location/Address/Hall/Webpage

Questions

Please give the specific location/webpage of the Accessibility Concern.(Required) This field is required.

Please describe your Accessibility Concern in as much detail as possible.(Required) This field is required.

Does this Accessibility issue pertain to a program or event at Purdue?(Required)

Yes No

This field is required.

Supporting Documentation

Photos, video, email, and other supporting documents may be attached below. 5GB maximum total size.
Attachments require time to upload, so please be patient after submitting this form.

Email me a copy of this report

Background Information

Location of Accessibility Concern

Questions

Supporting Documentation

Submission