Alternate Media and Additional Request

Alternate Media and Additional Materials Request

  1. It is My responsibility to inform SSD immediately if there are any change in my class schedule that will affect my request for alternate media.
  2. It is My responsibility to submit any materials requested as quickly as possible to SSD in order to expedite the production of my alternate media.
  3. It is My responsibility to check my campus email regularly for communications regarding the status of my alternate media.
  4. I am Aware that this request form is only for course material Including; textbooks, course packets, handouts and PowerPoints as listed on the official course syllabus and/or the CSUSB/PDC Coyote Bookstore textbook list.
  5. I am Aware that I must complete a separate Additional Materials Request form per class as needed.
  6. I Agree to sign and submit an official Copyright Agreement Form for each textbook prior to the release of my accessible materials.
  7. I Understand that I must provide proof of purchase (official Receipt from vendor) for each textbook I am requesting in accessible format.
Student Information
Term Information
Courses You Would Like Alternate Media For
Course 1 Information
Type of Material 1
Material
Type of Material 2
Material
Type of Material 3
Material
Type of Material 4
Material
Preferred Format
Method of Delivery
Course 2 Information
Type of Material 1
Material
Type of Material 2
Material
Type of Material 3
Material
Type of Material 4
Material
Preferred Format
Method of Delivery
Course 3 Information
Type of Material 1
Material
Type of Material 2
Material
Type of Material 3
Material
Type of Material 4
Material
Preferred Format
Method of Delivery
Course 4 Information
Type of Material 1
Material
Type of Material 2
Material
Type of Material 3
Material
Type of Material 4
Material
Preferred Format
Method of Delivery
Course 5 Information
Type of Material 1
Material
Type of Material 2
Material
Type of Material 3
Material
Type of Material 4
Material
Preferred Format
Method of Delivery