Student Life – Disability Resource Office
Alternative Format Request
(Complete one form per class)
Date of Request: _______________
Semester: _________________
Student Name: _______________________________________ PID #: _____________________
Phone: _______________________
E-Mail: _______________________________________
Type of Alternative Format:
Word File
Audio
Braille
Enlargement
Other: ________
The following outlines the process for requesting and receiving alternate format(s) of books and
classroom materials for students registered with the Disability Resource Office (DRO).
Requests should be made by me a minimum of 4 to 6 weeks prior to the first day of
class, or the date materials are needed. The DRO will make every attempt to provide
books/materials by the date needed.
I understand that if I do not submit a request according to the timeline above,
requested materials may not be available when needed.
The DRO will make every attempt to request an electronic version of the textbook from
the publisher. I understand that I may need to provide the DRO with a purchased book
if a copy cannot be obtained from the publisher within 2 weeks of my request.
In the process of scanning my book the DRO will cut the pages from the binding. When
the conversion process is completed the DRO, upon my request, will re-bind my book
and return it to me.
I agree that I will not copy or reproduce alternatively formatted books/materials nor
allow anyone else to do so pursuant to the requirements of the copyright revision act
of 1976 as amended. Any further reproduction or distribution is considered copyright
infringement.
I understand that I must provide proof of payment for books/materials to the DRO prior
to receiving any alternative formats.
I understand that I will be notified by e-mail using the address listed above when
alternative format books/materials are ready for pick up at the Disability Resource
Office, located in the Library and Academic Resources Center, Suite 169.
I acknowledge and understand the outlined process as described above.
___________________________________________ ________________________________
Student Signature
Date
Course Information:
Course Name and Number: _______________________________________________________
Instructor Name: _______________________________ Instructor Phone: _________________
Start Date for Course: _____________________ End Date for Course: ____________________
If the semester has already started, please attach your course syllabus.
Book Information:
1. Title: ___________________________________________________________________
Author(s): ______________________________ ISBN: ____________________________
Edition/Year Published: ___________________ Date Needed:_____________________
2. Title: ___________________________________________________________________
Author(s): ______________________________ ISBN: ____________________________
Edition/Year Published: ___________________ Date Needed:_____________________
3. Title: ___________________________________________________________________
Author(s): ______________________________ ISBN: ____________________________
Edition/Year Published: ___________________ Date Needed:_____________________
4. Title: ___________________________________________________________________
Author(s): ______________________________ ISBN: ____________________________
Edition/Year Published: ___________________ Date Needed:_____________________
Course Materials:
1. Title/Item: _______________________________________________________________
Description: _____________________________Date Needed:_____________________
2. Title/Item: _______________________________________________________________
Description: _____________________________Date Needed:_____________________
3. Title/Item: _______________________________________________________________
Description: _____________________________Date Needed:_____________________
4. Title/Item: _______________________________________________________________
Description: _____________________________Date Needed:_____________________
Revised: 1/22/15