On- Campus CLASSROOM & MEETING REQUESTS (2011-12) Survey

Only instructors or USI staff must complete form! Use this form for deliveries in classrooms or conference rooms on USI campus Only. We do not deliver to Offices. Questions? Contact us online: instructech.usi.edu or call 464-1838.

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1. Please type your name.

Please type your name.

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2. What is your complete EMAIL address?

What is your complete EMAIL address?

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3. Please enter a telephone number so we may call you, if we have a question about your request.

Please enter a telephone number so we may call you, if we have a question about your request.

4. Select the area where you work from the list below.

Select the area where you work from the list below.

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5. What is your course number or meeting?

What is your course number or meeting?

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6. Choose the building where equipment is to be delivered. If your building is not on drop down, add in "OTHER".

Choose the building where equipment is to be delivered. If your building is not on drop down, add in "OTHER".

Other (please specify)

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7. Please select room number for delivery. If not listed, scroll to last choice and click on "OTHER".

Please select room number for delivery. If not listed, scroll to last choice and click on "OTHER".

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8. Select equipment needed from the list below. If equipment is not on this list, it may be considered portable equipment and you need to choose that form & pick-up equipment from FA 048.

Select equipment needed from the list below. If equipment is not on this list, it may be considered portable equipment and you need to choose that form & pick-up equipment from FA 048. TV/DVD/VCR (TV with a DVD and VHS player)

TV/DVD/VCR with Scan converter (images from computer, DVD & VHS are displayed on TV screen)

LCD projector

LCD projector DVD/VCR

Compact music system (CD & cassette tape player)

Overhead projector(Call ITS if it is not in the classroom.)

Overhead transparency projector with acetate roll

Slide Projector

Slide projector with slide tray (holds 80 slides)

Easel (Need paper? Ask your fiscal agent to email ITS with approval & account # for charge back)

Screen - Classrooms are equipped with a screen or SmartBoard to project images onto.

Other

If Other please specify

9. Specify below if you need more than one. We DO NOT have any type of computers!
(You may skip this if it does not apply.)

Specify below if you need more than one. We DO NOT have any type of computers! (You may skip this if it does not apply.)

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10. Please select the semester that your class meets. If your course overlaps semesters, please specify.

Please select the semester that your class meets. If your course overlaps semesters, please specify.

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11. Is this a semester long loan, for every class?

Is this a semester long loan, for every class? Yes

No

12. If you need equipment 1-5 dates (but NOT entire semester), enter dates below in mm/dd/yy format. For example, if you need equipment on all Tuesdays in October of 2011, you would enter the following: 10/04/11,10/11/11,10/18/11,10/25/11. For semester loans, go to next question.

If you need equipment 1-5 dates (but NOT entire semester), enter dates below in mm/dd/yy format. For example, if you need equipment on all Tuesdays in October of 2011, you would enter the following: 10/04/11,10/11/11,10/18/11,10/25/11. For semester loans, go to next question.

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13. During FINALS WEEK, do you need equipment delivered?

During FINALS WEEK, do you need equipment delivered? Yes

No

14. If yes, what is the date and time of your final?

If yes, what is the date and time of your final?

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15. Select each day(s) you need equipment delivered to your classroom. (For a week-end class, choose Friday for delivery and Monday for pick-up. Please lock the equipment in your office or classroom.)

Select each day(s) you need equipment delivered to your classroom. (For a week-end class, choose Friday for delivery and Monday for pick-up. Please lock the equipment in your office or classroom.) Monday

Tuesday

Wednesday

Thursday

Friday

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16. Choose the time your class begins from the list below.

Choose the time your class begins from the list below.

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17. Please select the nearest time your class ends from the list below.

Please select the nearest time your class ends from the list below.

18. Questions? Concerns? Need technical support? Select any that apply from the list below.

Questions? Concerns? Need technical support? Select any that apply from the list below. I have a question; please contact me.

I need technical support (Note: Service is provided up to 3 times per classroom then charges will apply).

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