ODS Alternative Media Request Form and Agreement
Please fill out completely. Valid receipts must be attached for all requested materials.
Name (First and Last)
CSU ID
Section 1:
Course Information
Course
Course
Course
Professor
Professor
Professor
Syllabus
Syllabus
Syllabus
Course
Course
Course
Professor
Professor
Professor
Syllabus
Syllabus
Section 2:
Syllabus
Preferred Format (SELECT ONE)
PDF
Text
Section 3:
Word
Other Please specify
Preferred Method of delivery (SELECT ONE)
Drop Box
Flash Drive
Victor Stream
Other please specify
Section 4:
Alternative Media Agreement For Services
· I understand and agree to abide by the purchase and copyright agreements stated in the front of
textbooks and materials.
· I agree not to copy, distribute, upload to a server, or sell any reformatted material provided to me by The
Office of Disability Services (ODS).
· I understand that I must submit a syllabus and proof of purchase for every book I request.
· I understand that if I order materials and do not pick them up by the end of the semester, my alternative
media privileges will be suspended until I meet with my Disability Specialist.
· I will provide textbooks and other materials for reformatting. They will be in excellent condition. I
understand that documents with "dog-eared" pages, highlighter marks, or hand written notes may not be
accepted (will not scan well).
· ODS is not responsible for any damage to the original material during the reformatting process.
· I understand that I must notify ODS immediately if there are any changes in the status of a request, class
schedules, course requirements, alternative format needs, or if some or all the readings for a course are no
longer needed or if the course is dropped.
· I understand that I need to complete and submit an Alternative Media Request Form to ODS each term
for each item I would like to have reformatted.
· I have read and understood the Alternative Media Policies and Procedures Handbook.
By signing my name below, I agree I have read and understand these conditions.
(We encourage you to keep a copy of this agreement for your records.)
Student Signature
Date
Staff Signature
Date
Date Received
Date Logged
Date Scanned