Alternate Media Request Form
Rio Hondo College Alternate Media Services
Phone: (562) 908-3420
FAX: (562) 463-4651
Email: sfrederickson@riohondo.edu
□ Fall □ Winter □ Spring □ Summer
Requested for: (check one)
RHC Disabled Students
Program & Services
Today’s Date
Name
Student ID
Phone
Email
Course #
Instructor
Section
Course Title
**Book Title
Author
Edition/Year
Publisher
ISBN
**NOTE: For textbook information check the list at the Rio Hondo College Bookstore, or check their
website at www.efollett.com/.
Class Syllabus Received □ Yes
□ Will Bring 1st week of Semester □ Contact Professor for me
PLEASE CHOOSE ONE FORMAT (BELOW)
Preferred Format
_____ Taped Text
_____ Tactile Graphics
_____ CD Audio Text
_____ Braille (Grade 1 or 2, Nemeth, or Music)
_____ Close Captioned Video/DVD
_____ E-Text (Word, PDF, plain text, MP3 or TIF)
_____ Audio Captioned Video
_____ Large Print (16, 18, 20, 22, 24, etc. point)
_____ RFBD Shelf #
_____ HTC Computer Profile
Comments:
Terms and Conditions on Use of Alternate Media
I understand that any alternate media, which may be supplied to me, is solely for my own educational purposes. I will
not copy or distribute any such alternate media in violation of the Copyright Revisions Act of 1976, as amended (17
U.S.C. Sec. 101 et seq.). I understand that failure to abide by this agreement may constitute a violation of the Student
Code of Conduct, and/or Board policy. I understand that a violation of any college policy, including improper distribution
of electronic text, may result in suspension of DSPS services.
Student Signature __________________________________________________
Date ___________________
FOR OFFICE USE ONLY:
RECEIVED BY: __________________________________ DATE RECEIVED: _______________
COMMENTS: ___________________________________________________________________
Textbook Purchase Verification (Required for all E-text, Braille, etc. requests)
□
□
□
□
Instructional material supplied by the college to all students.
Student has purchased or ordered the standard instructional material. Attach copy of receipt.
Instructional material has been purchased or ordered by Department or Rehabilitation.
Attach copy of receipt.
Book is not yet available in the bookstore. Student agrees to purchase the book before
picking up the alternate media from DSPS. Attach copy of receipt when available.
Verification of Eligibility:
Authorization: ____________________________ Verification of Enrollment: _________________
Alternate Media Tech Use Only
Disability Code ______________
Original Material Information:
Publisher: ______________________________
Publisher Contact: ______________________
Pub. Address: ___________________________
Pub. Phone: ___________________________
Pub. 2nd Address: ________________________
Pub. FAX _____________________________
Pub. E-mail: _____________________________
Pub, Web Site: _________________________
Taped Text:
Available from RFB&D:
□ Yes
□ No
Date form sent to DSPS: _________________
Create E-text, TextAloud-MP3, record to tape: ___________________________________________
E-Text
Available from HTCTU:
□ Yes
□ No
Available from ATPC:
□ Yes
□ No
Ordered from: _____________________________________________________________________
Date Ordered: ________________________
Date Arrived: __________________________
Proof Read by: ________________________
Reformatted: __________________________
Archived by: __________________________
Media: ___________
In House E-Text
Date: ___________
Book/materials unbound: ________________
Material Scanned: ______________________
Material OCR’d: _______________________
Material Proof Read: ____________________
Book rebound: ________________________
Page 2 of 3
07/11/2006
Braille
Student reads:
□ Grade 1
□ Grade 2
□ Nemeth Braille □ Music Braille
E-Text obtained: ___________________________________________________________________
Convert e-text to Braille by: ______________________________
Date: ________________
Print and bind Braille: _______________________________________________________________
Braille ordered from outside source: ___________________________________________________
Closed Captioning
□ Yes □ No
Available from Publisher w Captions?
Other source?
□ Yes
□ No
Captioned Video Ordered: _______________________
Captioned Video Received: __________
Script available from Publisher? ___________________
Permission granted?
Script ordered: ________________________________
Script received: ___________________
Script created: ________________________________
Captioning file created: _____________
□ Yes
□ No
Location of captioned video: __________________________________________________________
Captioning ordered from outside source: ________________________________________________
ALL
□ Yes □ No
Date complete request received: _____
Format provided to student: ______________________
Date notified of timeline, format: ______
Date materials available: _________________________
Student notified by:
If media created locally, update AMEX?
Deadline to Pick up: ____________
Date Picked Up: ___________
□ Phone □ Email
Date Returned: __________
Adaptive Equipment Requested? ______________________________________________________
NOTES: