SYSTEM-WIDE ALTERNATIVE TEXT REQUEST FORM
Office of Accessibility
In order for your request to be processed, please:
1) Complete entire form
2) Attach receipt for each book requested
3) Attach Course Syllabus
4) Sign and date
Student Name: ________________________ Alliant ID#:___________ Today’s date: ___________ Program: _______________
Email: [email protected] Phone #: ____________________ Semester: (ex. Fall 2016) _________________
Format: ___ PDF (default) ___ Audio ___ Large Print ___Braille ___Other:_____________
Office use - Approved: Y N
Eligible students are asked to make requests for alternative format textbook(s) several weeks prior to the date for which the books
are needed. Processing time could take up to 6 weeks or longer and is dependent upon the publisher. The OOA will diligently
work to honor all requests, but late requests may not be fulfilled by the time books are needed. All accessible materials will be
provided in PDF format unless prior exception is requested and approved. When accessible books are ready, the OOA will make
them available to the student.
Students receiving these accessible materials are not permitted to share, distribute, or copy the materials or otherwise violate
copyright law. Failure to abide by this agreement may constitute a violation of the Student Code of Conduct and may result in the
suspension of this service. Also, failure to abide by copy right laws may result in civil or criminal prosecution, payment of fines or
other monies to the copyright holder, and/or incarceration.
In order to receive free accessible textbooks, the OOA requires proof of purchase for all requested books. The OOA will attempt
to acquire an electronic version of the book through the publishing company or other resources. Please keep in mind that all
books may not be available. Please check digital book recourses and e-readers online, to explore other options for obtaining
accessible books. Alternatively, students may schedule to bring in their books so the bindings can be cut, the book scanned and
made accessible. Please keep in mind that the process of cutting books can be lengthy.
I have read and understand the policies and procedures outlined above and agree to comply.
__________________________________
Print name
_____________________________
Signature
_________________
Date
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
1
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
2
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Note: In order to request alternative text through Alliant University, you must first have been approved by the Office of
Accessibility to use this academic accommodation. For more information, please see “How to Receive
Accommodations,” available on our web page (http://www. http://www.alliant.edu/consumer/disabilityservices/index.php) or see the campus OOA Coordinator.
SYSTEM-WIDE ALTERNATIVE TEXT REQUEST FORM
Office of Accessibility
Student:______________________________
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
3
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
4
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
5
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
6
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
____________________________________________________________________________
Title of book
10 or 13-digit ISBN
7
____________________________________________________________________________
Name of Author(s)
Publisher
Edition
____________________________________________________________________________
Course#
Name of class
Instructor
Price
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Office use only
___ Receipt
___ Syllabus
___ ATN
___ Publisher
___ Scanning
___ Other-_____
___ Received by Student
- Date____________
Note: In order to request alternative text through Alliant University, you must first have been approved by the Office of
Accessibility to use this academic accommodation. For more information, please see “How to Receive
Accommodations,” available on our web page (http://www. http://www.alliant.edu/consumer/disabilityservices/index.php) or see the campus OOA Coordinator.