Lake Superior State University
Lake Superior State University
 
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Disability Services - Alternative Request Form

Please complete a SEPARATE form for EACH REQUEST to be submitted. Each textbook, workbook, course reading packet, etc. will require a separate Alternate Format Request to be submitted.

 

 

  * = required field  
Today's Date: (Auto Entered)
*First Name: Type first name
*Last Name: Type last name
*LSSU Student ID Number: Type your nine digit alpha-numeric Student Id number in this field (Example: A00123456)
 
*Email: Type your email address. If you have more than one email, please use the one you check most frequently.
*Verify Email: Retype your email address.

*Home Phone:

Type your home phone number including area code in this field.

Alternate or Cell Phone:

Optional - Type cell phone number including area code.

*Semester:

From the three options (Fall, Spring, Summer), please select the semester this Alternate Format Request is being submitted for.

*Course Name:

Type the four letter abbreviation for the course name/number with section number, i.e., BIOL 121-001 for Biology 121-001, HIST 110-002 for History 110-002. Consult your class schedule for your course abbreviation and number.

*Faculty Name:

Type the name of the faculty teaching this course. Consult the class schedule for the name.
     

**Title of Material:

Type the title of the textbook, workbook, course reading packet, or other instructional material.

*Author:

Type the author's name. If more than one author, just list the first one.

*Publisher:

Type the publisher's name in this field.

Edition:

Type the edition number or year of publication.

*ISBN:

Type the ten digit ISBN number (leave out the dashes).
     
*Material Type: Article

Choose the type of material you are requesting we convert to another format. If you select the Other option, input the other material type in the field to the right. For example, Power Point presentation, overhead projection slides, digital file on CD, etc.

  Book
  Exam
  Handout
  Notes
  Other: Input Other Material Type
     
*Format Requested: Audio Format on Tape From the options please select the format you would like the material to be converted to. If you select the Other option, you will need to input the format in the field to the right. For example, tactile graphics, e-mail document, etc. If Large Print is selected, please include the font and size along with any other specific information in the Comments or Special Instructions section at the bottom of this form.
  Audio Format on CD
  Large Print
  MS Word Draft Quality
  MS Word Edited Quality
  Adobe PDF
  Other: Input Other Format
 

COMMENTS OR SPECIAL INSTRUCTIONS
Type any additional comments or special instructions in this field. Comments or special instructions can be up to 500 characters in length. If you feel there are additional details that might help ensure you receive your materials in the requested alternate format in a timely manner, please include them here. Your comments can help our staff serve you better.

 



You will also receive a copy of your submitted Alternate Request form in your email inbox. Please print or save this copy as your submission receipt.

Click the Submit button to send your completed Alternate Format Request form. If your Alternate Request form has been successfully submitted, you should be presented with another screen/webpage thanking you for your submission.

The Clear Form button will clear all the information from the Alternate Request form. Do not use it unless you intend to clear all the information from the Alternate Format Request form without submitting it.

Additional Assistance
If you have questions or would like additional assistance with completing the Alternate Request form, please contact Vicki Fox, Disability Services Coordinator and Alternate Format Services Specialist at (906635-2355 or vfox@lssu.edu.

 

Home » Alternate Format Request Form
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