Portable Equipment Request (2011-13) Survey

This form is to be completed by USI EMPLOYEES to borrow equipment for university-related activities ONLY, and is NOT FOR PERSONAL USE. A university account number is required- charges may apply. Questions? Contact us online at instructech.usi.edu , or call us at 464-1838.

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1. Please type your name.

Please type your name.

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2. Please type your complete EMAIL address.

Please type your complete EMAIL address.

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3. Type the telephone number where you may be reached if we have any questions.

Type the telephone number where you may be reached if we have any questions.

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4. Select area where you work at USI.

Select area where you work at USI.

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5. Please have the fiscal agent email IT their approval and provide an account number.This account will be charged in the event the equipment is damaged.

Please have the fiscal agent email IT their approval and provide an account number.This account will be charged in the event the equipment is damaged.

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6. State the meeting or the purpose for the loan.

State the meeting or the purpose for the loan.

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7. Select the equipment you need from the list below:

Select the equipment you need from the list below: Boombox- w/CD player & cassette tape player

Cassette tape recorder

DVD player

DVD/VCR player (combination player- plays dvd's & vhs tapes)

Easel

Easel paper pad (May be purchased from IT, fiscal approval and account number needed.)

Extension Cord

Flip video camcorders (upload up to 2 hrs. video to Internet)

Laser pointer

LCD data projector (projects computer images)

MP3 digital voice recorder

Overhead transparency projector

Portable sound system (includes microphones)

Projection Screen 6'

Scan converter (projects computer images on TV)

Slide projector

Slide projector w/ slide tray (holds 80 slides)

Sony Cybershot - digital camera

Sony mini digital-video recorder (you may buy mini-dv tapes from ITS OR elsewhere)

Turning P. Clickers

Turning POINT RECEIVER

Wireless Presenter

Need more than one of any item listed? (please specify)

8. Didn't see what you need on the list above?

Didn't see what you need on the list above?

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9. What date do you need to pick up equipment?

What date do you need to pick up equipment?

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10. Type the time you need to pick up the equipment. PICK-UP TIMES ARE: M-F 8:00 a.m. to 4:15 p.m.

		HH		MM	AM/PM
Pick up time:		Type the time you need to pick up the equipment. PICK-UP TIMES ARE: M-F 8:00 a.m. to 4:15 p.m. Pick up time: Hour	:	Minute	AM or PM

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11. What date will you return equipment?

What date will you return equipment?

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12. Time you will be returning equipment. RETURN during business hours: M-F 8 a.m. to 4:15 p.m.

		HH		MM	AM/PM
Return time:		Time you will be returning equipment. RETURN during business hours: M-F 8 a.m. to 4:15 p.m. Return time: Hour	:	Minute	AM or PM

13. IF THIS DOES NOT APPLY, skip question. Select box if you have questions or need assistance.

IF THIS DOES NOT APPLY, skip question. Select box if you have questions or need assistance. I will need a demonstration on the equipment.

I have a question; please contact me.

PLEASE PRINT A COPY of this completed form for your records and review it before continuing.