Alternate Format Textbook Request Form

Center for Student Accessibility 1P-101
Christopher Cruz-Cullari, Director
Alternate Format Textbook Request Form

Date: 05/22/2013

*Last Name:		*First Name:				Middle Initial:
*Student e-mail address:
*Course Name:		Instructor:
*Textbook Name:	*Textbook Edition:			*Textbook Author:
*ISBN Number:		*Semester:			*Year:
*Is this the required course textbook? Yes No		Is this textbook an optional resource? Yes No
*Preferred alternate textbook format:	*Delivery method:			* Purchase Date of Textbook: (2-Digit Month/2-Digit Day/4-Digit Year)
*Bookstore where textbook was purchased:			*Purchase price: $ Dollar . Cents
*Receipt on file at The Center for Student Accessibility? Yes No		*Course syllabus on file at The Center for Student Accessibility? Yes No

Note: This accommodation is provided on a first come, first serve basis. Because this process takes time, we encourage you to plan ahead. The sooner you submit your request (with all required materials attached), the more likely you are to get your material soon enough for your class. It is important that all necessary information be filled out on this request form, along with all required documentations attached.

You are approved for this accommodation based on the documentation we have on file. The Center for Student Accessibility will attempt to obtain the alternate format of the text (based on your preference) from publishers, RFB&D, or from Bookshare.org. Where these are not available, CSA will begin in-house conversion which may take some time. Please be sure to inform CSA if you have dropped a course and/or will no longer need the material.

An electronic file (E-text) is copyrighted and may not be reproduced or distributed in a format other than a specialized format exclusively reproduced for use by students with a documented disability that prohibits the person's use of instructional materials in standard print formats. Any reproduction or distribution in a format other than a specialized format is an infringement of the copyright law. Misuse of the specialized format will result in disciplinary action by the University Judicial Officer.

Student Signature (check box for electronic signature ) Date :___________________ Staff Signature: ________________________

CSA STAFF ONLY: Staff Notes: ________________________________ Approved/Available Format: E-text Audio Braille

Date Request completed: ________________ Staff: ________________ Date Material is received: ________________ Staff: ________________

Date Material is formatted: ________________ Staff: ________________ Date Student is contacted: ________________ Staff: ________________

Date Picked up: ________________Staff: ________________

Available in alternative format upon request

Updated: May 2010