January 2010 Textbook Request Survey

January 2010 Textbook Request

1. Please complete the following information:

Please complete the following information: Name:
Center:
Address:
Address 2:
City/Town:
State:
ZIP/Postal Code:
Student ID:
Email Address:
Phone Number:

2. Documentation of your print disability must be submitted with this application. Documentation must be recent for the diagnosis and, if applicable, include evaluation measures that are adult referenced. Valid documentation is a comprehensive report prepared by the qualified professional who diagnosed the disability that includes the following information:
- Diagnostician’s credentials
- A discussion of the manner used to evaluate the student, including any standardized testing measures and scores obtained
- A statement of diagnosis
- A discussion the diagnosis and the student’s ability to perform major life activities
- Recommendations for reasonable accommodations

**If you need to submit documentation, please either fax to (518) 587-9716 or mail to:
Office of Collegewide Disability Services, 1 Union Avenue, Saratoga Springs NY 12866
Choose one of the following:

Documentation of your print disability must be submitted with this application. Documentation must be recent for the diagnosis and, if applicable, include evaluation measures that are adult referenced. Valid documentation is a comprehensive report prepared by the qualified professional who diagnosed the disability that includes the following information: - Diagnostician’s credentials - A discussion of the manner used to evaluate the student, including any standardized testing measures and scores obtained - A statement of diagnosis - A discussion the diagnosis and the student’s ability to perform major life activities - Recommendations for reasonable accommodations **If you need to submit documentation, please either fax to (518) 587-9716 or mail to: Office of Collegewide Disability Services, 1 Union Avenue, Saratoga Springs NY 12866 Choose one of the following: Documentation is already on file

I will be sending documentation

I do not have documentation

3. What software or playback device will you use to access your textbook?

What software or playback device will you use to access your textbook?

4. Please rate the following text options. Please note: the disability services office will try to get your preferred format. However, if your preferred format is not available, we may substitute another format that is available.

	Most preferred	Preferred	Accessible	Cannot use
RFB&D audio	Please rate the following text options. Please note: the disability services office will try to get your preferred format. However, if your preferred format is not available, we may substitute another format that is available. RFB&D audio Most preferred	Preferred	Accessible	Cannot use
MP3	MP3 Most preferred	Preferred	Accessible	Cannot use
PDF	PDF Most preferred	Preferred	Accessible	Cannot use
DAISY	DAISY Most preferred	Preferred	Accessible	Cannot use
Word	Word Most preferred	Preferred	Accessible	Cannot use
Braille	Braille Most preferred	Preferred	Accessible	Cannot use

5. Acknowledgements:
- Book requests may take as long as 6-8 weeks to fulfill, depending on the source of the alternative format.
- Students requesting electronic file formats need to submit a receipt or packing list to prove that the titles have been purchased.
- Students purchasing text materials from the Empire State College Online Bookstore and requesting electronic file formats need to ship their books to the Office of Collegewide Disability Services in Saratoga to be held for scanning. Books will be shipped to the student once a file has been obtained from the publisher or scanned by the college.
- Texts scanned in Saratoga will be unbound for scanning purposes. All books will be rebound prior to shipment to the student.
- Alternatively formatted files are limited to use by the student submitting this request only. Files are not to be shared or sold in any manner. If a student sells his or her print copy of the textbook, he or she must return the alternatively formatted copy of the textbook to the Office of Collegewide Disability Services.

Acknowledgements: - Book requests may take as long as 6-8 weeks to fulfill, depending on the source of the alternative format. - Students requesting electronic file formats need to submit a receipt or packing list to prove that the titles have been purchased. - Students purchasing text materials from the Empire State College Online Bookstore and requesting electronic file formats need to ship their books to the Office of Collegewide Disability Services in Saratoga to be held for scanning. Books will be shipped to the student once a file has been obtained from the publisher or scanned by the college. - Texts scanned in Saratoga will be unbound for scanning purposes. All books will be rebound prior to shipment to the student. - Alternatively formatted files are limited to use by the student submitting this request only. Files are not to be shared or sold in any manner. If a student sells his or her print copy of the textbook, he or she must return the alternatively formatted copy of the textbook to the Office of Collegewide Disability Services. I agree

1. Default Section

1. Please complete the following information:

3. What software or playback device will you use to access your textbook?

4. Please rate the following text options. Please note: the disability services office will try to get your preferred format. However, if your preferred format is not available, we may substitute another format that is available.