Service Request At the bottom of the form, you will need to sign your name indicating that you have read and agree to the above responsibilities and statements. Student Information First Name Last Name Coyote ID CSUSB Email Phone Number Phone Type Home Work Cell Campus Main CampusPDC Campus Class Schedule Please list only those courses for which you are requesting a service. Request Term - Select -FallWinterSpringSummer - RegularSummer - 6W1Summer - 6W2 Request Year - Select -201920202024202120222023 Number of Classes - Select -123456 Class 1 Course Class # / Section Instructor Day / Time Location Requests for This Course 1 Accessible Furniture Request Form Captioning Service Request Form Class Aide Request Form Interpreter Request Form Memo Request Form Note Taker Request Form Smartpen Request Form Visual Impairment Orientation Request Form William FM Sound System Cart Service Are wheelchair accommodations necessary? Yes No Choose one Manual wheelchair Motorized wheelchair Class 2 Course Class # / Section Instructor Day / Time Location Requests for This Course 2 Accessible Furniture Request Form Captioning Service Request Form Class Aide Request Form Interpreter Request Form Memo Request Form Note Taker Request Form Smartpen Request Form Visual Impairment Orientation Request Form William FM Sound System Cart Service Are wheelchair accommodations necessary? Yes No Choose one Manual wheelchair Motorized wheelchair Class 3 Course Class # / Section Instructor Day / Time Location Requests for This Course 3 Accessible Furniture Request Form Captioning Service Request Form Class Aide Request Form Interpreter Request Form Memo Request Form Note Taker Request Form Smartpen Request Form Visual Impairment Orientation Request Form William FM Sound System Cart Service Are wheelchair accommodations necessary? Yes No Choose one Manual wheelchair Motorized wheelchair Class 4 Course Class # / Section Instructor Day / Time Location Requests for This Course 4 Accessible Furniture Request Form Captioning Service Request Form Class Aide Request Form Interpreter Request Form Memo Request Form Note Taker Request Form Smartpen Request Form Visual Impairment Orientation Request Form William FM Sound System Cart Service Are wheelchair accommodations necessary? Yes No Choose one Manual wheelchair Motorized wheelchair Class 5 Course Class # / Section Instructor Day / Time Location Requests for This Course 5 Accessible Furniture Request Form Captioning Service Request Form Class Aide Request Form Interpreter Request Form Memo Request Form Note Taker Request Form Smartpen Request Form Visual Impairment Orientation Request Form William FM Sound System Cart Service Are wheelchair accommodations necessary? Yes No Choose one Manual wheelchair Motorized wheelchair Class 6 Course Class # / Section Instructor Day / Time Location Requests for This Course 6 Accessible Furniture Request Form Captioning Service Request Form Class Aide Request Form Interpreter Request Form Memo Request Form Note Taker Request Form Smartpen Request Form Visual Impairment Orientation Request Form William FM Sound System Cart Service Are wheelchair accommodations necessary? Yes No Choose one Manual wheelchair Motorized wheelchair Memo Request Who is your counselor? Physical & Visual Disabilities Specialist Dr. Ben Toubak Alyssa Bradley Marci Daniels Rosie Garza Smartpen Request Have you checked out a smartpen from SSD before? Yes No When was the last quarter? Fall Winter Spring Summer - Regular Summer - 6W1 Summer - 6W2 Year Have you watched a smartpen tutorial? Yes No Your Responsibilities if Requesting Accessible Furniture It is MY responsibility as a new student to meet with my SSD Counselor at least ten (10) working days prior to the start of the quarter to review my request for Accessible Furniture. It is MY responsibility as a current student to submit my request to the SSD office at least ten (10) working days prior to the start of each quarter if the request is the same as prior quarters. It is MY responsibility to submit my request to the SSD office at least twenty (20) working days prior to the start of the quarter if the request is a modification of a prior request or a new request. For all modifications and new requests, students are required to meet with their SSD Counselor at least ten (10) working days prior to the start of the quarter to review the request. It is MY responsibility to inform SSD immediately should there be any change in my class schedule, classroom location, cancellation of service, or any questions or concerns. Your Responsibilities if Requesting a Captioning Service It is MY responsibility to submit a completed Captioning Service Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to communicate with SSD immediately should there be any change in my class schedule that may affect my request for captioning services. It is MY responsibility to maintain communication with SSD regarding my captionist(s). It is MY responsibility not to share the transcripts with any of my classmates and I have been advised to destroy the transcripts when the quarter ends. Your Responsibilities if Requesting Class Aide It is MY responsibility to submit a completed Class Aide Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to communicate with SSD immediately should there be any change in my class schedule or location that will affect my request for a Class Aide. It is MY responsibility to maintain communication with SSD regarding my Class Aide request. Your Responsibilities if Requesting an Interpreter It is MY responsibility to submit a completed Interpreter Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to communicate with SSD immediately should there be any change in my class schedule that may affect my request for an Interpreter. It is MY responsibility to maintain communication with SSD regarding my Interpreter. Your Responsibilities if Requesting a Memo It is MY responsibility to submit this form to SSD, which may be obtained from the SSD Office or on the SSD Website. It is MY responsibility to submit the memos I receive from the SSD Office to my instructors. I am aware that once I submit the Memo Request Form, SSD will prepare the memos within two (2) working days. I will pick up the memos at the SSD office during normal business hours. Your Responsibilities if Requesting a Note Taker It is MY responsibility to submit a completed Note Taker Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to communicate with SSD immediately should there be any change in my class schedule or location that may affect my request for a Note Taker. It is MY responsibility to maintain communication with SSD regarding my Note Taker Request. I am aware that class notes may also be photocopied at SSD during normal business hours within a timely manner. Your Responsibilities if Requesting a Smartpen It is MY responsibility to submit a completed Smartpen Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to communicate with SSD immediately should there be any change in my class schedule that may affect my request for a smartpen. It is MY responsibility to maintain communication with SSD regarding my smartpen request. I am aware that smartpens are limited and submitting a request does not guarantee the equipment will be available. Your Responsibilities if Requesting Visual Impairment Orientation It is MY responsibility to submit a completed Visual Impairment Orientation Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to establish and maintain communication with SSD regarding my Visual Impairment Orientation request. I am aware that I may request an orientation appointment with an SSD designee to orient myself to my classrooms, campus buildings or locations. I am aware that the visual impairment orientations offered by SSD do not take the place of Orientation and Mobility training provided by professional trainers through the Department of Rehabilitation. Students who require Orientation and Mobility training will be referred to the Depart of Rehabilitation. I am aware that I will be contacted by SSD within two (2) working days to schedule the orientation. Your Responsibilities if Requesting a William Sound FM System It is MY responsibility to submit a completed William Sound FM System Request form to SSD at least thirty (30) days prior to the first day of classes each quarter. It is MY responsibility to communicate with SSD immediately should there be any change in my class schedule that may affect my request for a William Sound FM System. It is MY responsibility to maintain communication with SSD regarding my FM System request. I am aware that William Sound FM Systems are limited and submitting a request does not guarantee the equipment will be available. I have read and agree to the above responsibilities and statements. Student Signature