OFFICE OF SPECIAL SERVICES
Braille Request Form
Semester:_________________________________
COURSE MATERIAL:*
Check box:
Name:____________________________________
ID:_______________________________________
:
Phone:____________________________________
:
E-mail:____________________________________
:
Request Date: ______________________________
:
Date Needed:_______________________________
Course:____________________________________
Chapters/Pages: _____________________________





TEXT BOOK
WORKBOOK
HANDOUTS
DOCUMENTS
NOTES
TYPE OF BRAILLE
REQUESTED:




GRADE 1
GRADE 2
NEMETH
TACTILE
*Students: Please let us know if you would like us to include the table of
contents, index and/or appendix.
Signature: _____________________________
Date: ________________
FOR OFFICE USE ONLY






Verified for accommodations
Copy of course syllabus
Copy of registration receipt
Copy of book receipt
Scan Book
Book rebound
 Yes
 No
 Requested from ATPC/AMX/RFBD/HTC Library/Bookshare.org
CALL FOR PICK UP DATE/TIME: _______________________________
ALT MEDIA/EQUIPMENT PICK-UP DATE: _______________________
ALT MEDIA/EQUIPMENT RETURNED DATE: ____________________
PHYSICAL TEXTBOOK RETURNED DATE:_______________________
ALT MEDIA OWNED BY STUDENT: _____________________________
Revised: 05/07/12
OFFICE OF SPECIAL SERVICES
Alternate Media/Equipment Request
Checkout and Use Agreement
Date:
Name: _
Semester:
Fall
Winter
Spring
Summer
201___
SID#:
ALTERNATE MEDIA/EQUIPMENT PROCEDURES
Note: When requesting Alternate Media Formats/Equipment:
 Students must be approved by OSS for alternate media/assistive technology as an accommodation
before services are provided.
 Each textbook request must be submitted to the High Tech Center with the purchased textbook.
Due to copyright laws, all students are required to purchase textbooks. If a textbook needs to
be scanned, it must be taken apart. State if you want the textbook rebound.
 Include: A copy of the book receipt.
A copy of the instructor's syllabus.
A copy of your current class schedule
 Students will be notified by telephone when requests are available to be picked up. At that time,
students will complete the Checkout & Use Agreement below. At the end of each semester,
alternate media must be returned to OSS (unless student provides their own CD), as they are the
property of the institution. Any CD, Braille and/or equipment not returned will affect future
registration and provision of services by the Office of Special Services.
 Due to the quantity of work involved in converting books into alternate media , please inform
our office as soon as possible if you drop a class. Failure to notify may result in loss of
OSS services.
Equipment Checked Out: ______________________________________________________________
for the period of: _____________ to _____________.
CHECKOUT AND USE AGREEMENT
I, ___________________________ understand the Office of Special Services’ policy for the use of
alternate media and agree to abide by the following checkout guidelines. Specifically, I will not sell,
share, duplicate or distribute the alternate media material and will return al l borrowed equipment to
OSS by the specified date. In addition, I understand the alternate media/equipment is the property of
OSS and any violation of this directive may be cause for suspension of future services with OSS, and
if alternate media/equipment is not returned, a hold will be placed on my LACC registration and
records. Students are responsible for paying the replacement cost of equipment that is not returned by
the specified date above. By signing said agreement, I have received the alternate media/equipment,
my original textbook and agree to stated guidelines.
Signature: _____________________________
Date: _________________________
Emergency/Alternate Contact:
Name: _____________________
Revised: 05/07/12
Phone: _____________
Email: _____________________
OFFICE OF SPECIAL SERVICES
Textbook Request Form
Date:
Name: _
SID# :
Semester:
Fall
Winter
Spring
Summer
201___
Book ____________________________________________________________ _____________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Book _________________________________________________________________________
ISBN: _________________ Type:
CD Braille
USB
SD Card Large Print
Revised 05/07/12