Accessible Format Request Form Instructions
Please complete a SEPARATE form for EACH REQUEST to be submitted. Each textbook, workbook, course reading packet, etc. will require a separate Accessible Format Request to be submitted.
Note : Fields with an asterisk (*) are required. Failure to include information in required fields will prevent your Accessible Format Request from being submitted.
Type your nine digit numeric Campus-Wide Identification number in this field.
Type your first name in this field.
Type your last name in this field.
Type your home phone number including area code in this field. This should be the phone number you use for your residence while attending the university.
Type your cell phone number including area code in this field. If you do not want the Accessible Format Services staff to contact you on your cell phone, please leave this field blank. It is not a required field. However, we recommend you allow the Accessible Format Services staff to contact you on your cell phone because this is often the most timely way to contact students when there are questions about their Accessible Format Requests.
Type your email address in this field. If you have more than one email address, please provide the email address you check most frequently.
Type your email address again in this field. Please type the same email address as in the Email field above to verify its accuracy.
From the four options (Fall, Intersession, Spring, Summer), please select the semester this Accessible Format Request is being submitted for. If there are additional details related to the semester such as a specific session during the Summer or Intersession, please include these details in the Comments or Special Instructions section at the bottom of this form.
Type the three or four letter abbreviation for the course name (College or Department) along with the course number in this field. For example, BIOL 171 for Biology 171, HIST 110 for History 110, SPED 342 for Special Education 342, etc. Consult the class schedule for your course abbreviation and number.
Type the five digit code number for the course in this field. For example, 12345. Consult the class schedule for your course code number.
Type the name of the faculty member teaching the course in this field. For example, J. W. Hoese. Consult the class schedule for the name of your course faculty member.
*Title of Material:
Type the complete title of the textbook, workbook, course reading packet, or other instructional material in this field.
Type the complete author's name in this field.
Type the complete publisher's name in this field.
Type the edition number or year of publication in this field.
Type the ten digit ISBN number in this field.
From the six options (Article, Book, Exam, Handout, Notes, Other) please select the type of material you are requesting to be converted to an accessible format. If you select the Other option, you will need to input the other material type in the field to the right of the Other option. For example, Power Point presentation, overhead projection slides, digital file on CD, etc.
From the seven options (Audio Format, Braille, Kurzweil 3000 Draft Quality, Kurzweil 3000 Edited Quality, Large Print, RTF, Other), please select the accessible format you would like the material to be converted into. If you select the Other option, you will need to input the other format requested into the field to the right of the Other option. For example, tactile graphics, MS Word, PDF, etc. If Large Print is selected, please include the font style and point size along with any other specific information in the Comments or Special Instructions section at the bottom of this form.
Note: Please allow 1 to 2 weeks for delivery of requested materials in Kurzweil 3000 Draft Quality format and 2 to 6 weeks for delivery of requested materials in Kurzweil 3000 Edited Quality format. All delivery estimates begin from the date the material is available for production, not from the time the Accessible Format Request is submitted. Kurzweil 3000 Draft Quality requests will be high-quality drafts but not free from errors. Kurzweil 3000 Edited Quality requests will be edited for readability and accuracy of text.
COMMENTS OR SPECIAL INSTRUCTIONS
Type any additional comments or special instructions in this field. Comments or special instructions can be up to 500 characters in length. If you feel there are additional details that might help ensure you receive your materials in the requested accessible format in a timely manner, please include them here. Your comments can help our staff serve you better.
Submit Form (Button)
Click on this button to submit your completed Accessible Format Request form. If your Accessible Format Request form has been successfully submitted, you should be presented with another screen/webpage thanking you for your submission. You will also receive a copy of your submitted Accessible Format Request form in your email inbox. Please print or save this copy as your submission receipt.
Clear Form (Button)
This button will clear all the information from the Accessible Format Request form. Do not use it unless you intend to clear all the information from the Accessible Format Request form without submitting it.
If you have questions or would like additional assistance with completing the Accessible Format Request form, please contact Amanda Pinedo, Accessible Instructional Material Specialist, at (657) 278-3118 or firstname.lastname@example.org.
Last updated July 1, 2013