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Alternate Format Textbook Request Form - Center for Student Accessibility 1P-101
Date: 05/25/2017

*Is this the required course textbook?
Is this textbook an optional resource?
*Purchase price: $ .
*Receipt on file at The Center for Student Accessibility?
*Course syllabus on file at The Center for Student Accessibility?

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, https://www.learningally.org/ formally ( RFB&D), or from https://www.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.

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

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

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

Date Material is formatted: ________________ Staff: ________________ Date E-mailed: ________________ Staff: ________________

Date Picked up: ________________Staff: ________________                                      

Available in alternative format upon request  Updated: April 2015