Phone: (562) 908-3420
Requested for: (check one) FAX: (562) 463-4651
□ Fall □ Winter □ Spring □ Summer Email: sfrederickson@riohondo.edu
RHC Disabled
Students
Program
& Services
Today’s Date
Terms and Conditions on Use of 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 ___________________ Page 1 of 3 07/11/2006
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: _________________
Page 2 of 3 07/11/2006 Page 3 of 4 07/11/2006
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:
___________ Date: ___________
In House E-Text
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
Page 3 of 3 07/11/2006
E-Text obtained:
___________________________________________________________________
Convert
e-text to Braille by: ______________________________ Date: ________________
Print
and bind Braille:
_______________________________________________________________
Braille
ordered from outside source:
___________________________________________________
Closed Captioning
Available from Publisher w Captions? □ Yes □ No Other
source? □ Yes □ No
Captioned
Video Ordered: _______________________ Captioned
Video Received: __________
Script available from Publisher? ___________________ Permission
granted? □ Yes □ No
Script
ordered: ________________________________ Script
received: ___________________
Script
created: ________________________________ Captioning
file created: _____________
Location
of captioned video: __________________________________________________________
Captioning
ordered from outside source: ________________________________________________
ALL
If
media created locally, update AMEX? □ Yes □ No Date
complete request received: _____
Format
provided to student: ______________________ Date
notified of timeline, format: ______
Date
materials available: _________________________ Student
notified by: □ Phone □ Email
Deadline
to Pick up: ____________ Date Picked Up: ___________ Date Returned: __________
Adaptive
Equipment Requested? ______________________________________________________
NOTES:
Page 3 of 3 07/11/2006
