Los Angeles Valley College
Disabled Students Program and Services
Alternate Media Format Assessment
Name: ID #:
Telephone #: Email #:
This student has a print-related disability that prevents him/her from using standard formats. Verification of a print-related disability is on file in DSPS.
q Yes
DSPS Counselor /Disability Specialist Date
q No
Describe educational limitations related to need for alternate media format:
Preferred Alternate Media Format
q Electronic Text: RTF DOC PDF Other:
q Audio: Tape CD MP3 Other:
q Large Print: Font and Size:
q Braille:
q Tactile Graphics
q Other:
q Not sure
q I have used this alternate media format. Where?
q I need assistance learning how to utilize alternate media format.
Comments:
Approved:
DSPS Instructional Assistant Signature Date
Los Angeles Valley College
Disabled Students Program and Services
Alternate Media Format Information and Use Agreement
Student Name: Semester/Year:
§ I understand that it takes two to three weeks (often longer) for DSPS to produce or obtain alternate media formatted materials. I will keep this in mind and register during priority registration and request alternate text format at that time.
§ I will use the Alternate Media Format Request (AMFR) form to request instructional materials in alternate format each semester.
§ I will purchase the standard instructional material(s) in original format. I understand that I must have the standard copy of the instructional materials in hand in order to acquire the alternate format version.
§ A copy of my class schedule printout for the semester will be attached to the AMFR. If I make any changes in this schedule I will inform DSPS immediately.
§ The instructional materials I have requested in alternate media format are required for my classes. I will provide a copy of the course syllabus for each class in which alternate formats have been requested to DSPS by the first week of the semester or sooner.
§ I have a documented disability that prevents me from using standard instructional materials.
§ I will meet with my DSPS Counselor and/or Disability Specialist to request accommodations each semester.
§ I have read and understand the procedures for acquiring instructional materials in alternate formats and electronic text.
§ I understand that any alternate media format instructional materials supplied to me are to be used solely for my own educational purposes. I agree not to copy or distribute the formatted materials. Copying or distributing any electronic text is in violation of the Copyright Revisions Act of 1976, as amended (17 U.S.C. Sec. 101 et. seq.) and DSPS policy.
§ I understand that failure to abide by this agreement may constitute a violation of the Student Code of Conduct, and/or of the college policy regarding responsible use of DSPS services.
§ I also understand that I am responsible for returning all alternate formatted materials to DSPS at the end of each semester. If the materials have not been returned to DSPS by the end of the semester, a hold will be placed on my records and I will not be able to enroll in classes or obtain copies of my transcripts until the materials have been returned or replaced.
§ If my request for text in alternate media is denied, I have the right to appeal through Section 4 of the LACCD Administrative Regulation (E-100) policy for serving students with disabilities. Copies of this policy can be obtained from DSPS, the Student Services office, or from the LACCD website < http://www.laccd.edu/admin_regs/>.
I agree to comply with DSPS policy and procedures.
Student Signature Date
DSPS Counselor/Staff Signature Date