University of Delaware
Office of Disability Support Services
Alternative Text Request Form
Please complete and return this form along with a copy of your book receipt(s) to the Office of Disability Support
Services. Requests are processed in the order in which they are received.
_____________________________________
Student Name
______________________
Phone Number
_______________________
Alternate Format Requested*
______________________________________
Student Email
_______________________
Semester and Year
______________________
Date Received in DSS
1.
Course Name and Number **
Instructor’s Name
Book Title
ISBN #
Author(s)
Publisher
Copyright
Edition
2.
Course Name and Number **
Instructor’s Name
Book Title
ISBN #
Author(s)
Publisher
Copyright
Edition
3.
Course Name and Number **
Instructor’s Name
Book Title
ISBN #
Author(s)
Publisher
* Alternate Format types include: Kurzweil, MP3, Word, and TextHelp
** Please provide a syllabus for each class in which alternate text is requested.
Copyright
Edition