* = required field
Today's Date:
(Auto Entered)
* First Name:Type your first name in this field
* Last Name:Type your last name in this field.
* LSSU Student ID Number: Type your nine digit alpha-numeric Student Identification number in this field (Example: A00123456)
* Email: Type your email address in this field. If you have more than one email address, please provide the email address you check most frequently.
* Verify Email: Type your email address again in this field. Please type the same email address as in the Email field above to verify its accuracy.
* Home Phone:
Type your home phone number including area code in this field. This should be the phone number you use for your residence while attending the university.
Cell Phone:
Type your cell phone number including area code in this field. If you do not want the Alternate Format Services staff to contact you on your cell phone, please leave this field blank. It is not a required field. However, we recommend you allow the Alternate Format Services staff to contact you on your cell phone because this is often the timeliest way to contact students when there are questions about their Alternate Format Requests.
* Semester:
Select One
Fall
Spring
Summer
From the three options (Fall, Spring, Summer), please select the semester this Alternate Format Request is being submitted for. If there are additional details related to the semester such as a specific session during the Summer, please include these details in the Comments or Special Instructions section at the bottom of this form.
* Course Name:
Type the four letter abbreviation for the course name (College or Department) along with the course and section number in this field. For example, enter BIOL 121-001 for Biology 121-001, HIST 110-002 for History 110-002, and so on. Consult your class schedule for your course abbreviation and number.
* Faculty Name:
Type the name of the faculty member teaching the course in this field. For example, V. D. Fox. Consult the class schedule for the name of your course faculty member.
* *Title of Material:
Type the complete title of the textbook, workbook, course reading packet, or other instructional material in this field.
* Author:
Type the complete author's name in this field. If more than one author, just list the first one.
* Publisher:
Type the complete publisher's name in this field.
Edition:
Type the edition number or year of publication in this field.
* ISBN:
Type the ten digit ISBN number (exclude dashes) in this field.
* Material Type:From the six options (Article, Book, Exam, Handout, Notes, Other) please select the type of material you are requesting to be converted to an alternate format. If you select the Other option, you will need to input the other material type in the field to the right of the Other option. For example, Power Point presentation, overhead projection slides, digital file on CD, etc.
* Format Requested:From the options (Audio Format on tape, Audio Format on CD, Large Print, MS Word Draft Quality, MS Word Edited Quality, Adobe PDF, Other), please select the alternate format you would like the material to be converted into. If you select the Other option, you will need to input the other format requested into the field to the right of the Other option. For example, tactile graphics, e-mail document, etc. If Large Print is selected, please include the font style and point size along with any other specific information in the Comments or Special Instructions section at the bottom of this form.
COMMENTS OR SPECIAL INSTRUCTIONS
You will also receive a copy of your submitted Alternate Format Request form in your email inbox. Please print or save this copy as your submission receipt.
Click the Submit button to submit your completed Alternate Format Request form. If your Alternate Format 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 Format Request form. Do not use it unless you intend to clear all the information from the Alternate Format Request form without submitting it.
