INSTRUCTOR 
											TECHNOLOGY, DISABILITY
											

											&/OR

											" BACK TO BACK " CLASSROOM

											REQUEST FORM

										
											FALL, SPRING & SUMMER COURSES		
							

							

								

									Please complete all sections of this form.		
							

							

								
									
CLASSROOM REQUEST

										
							

							
							

								Instructor:
										
							

							

								Phone:
										 Email: 
										
							

							

								Department:
										
							

							

								Course Rubric: 
										 Number: 
											Section: 
							

							

								Semester:
										 Course Max Limit: 
							

							

								Do you have a 
											Documented Medical Disability?: 
									
									
							

							

								TECHNOLOGY 
												INFORMATION:
All Classrooms (Basic): Projector 
											screen, overhead projector, VHS playback (with video monitor or projector), and 
											chalkboard. Please do not request this equipment.

										
Laptop Ready Rooms: Network connection at teaching station, 
											computer display, campus cable television, telephone (on-campus calls only), 
											lighting controls, window treatment, power and remote control for slide 
											projector, projected image and chalkboard can be used simultaneously, ELMO.

										
Multimedia Room: Laptop ready equipment plus-PC and MAC 
											installed, Elmo, laser disk player, slide projector, and cassette deck (audio).

										

									
										
							

							

								

											
Technology Requested: (choose one)


													

													

									
										
							

							

								

											
Other Information (Please list disability needs here and "back to back" 
													courses): 
												

													

									
										
							

							

								There are many 
										requests for multimedia classrooms. Not all requests can be accommodated. If a 
										multimedia room is requested and cannot be scheduled, we will schedule a 
										laptop-ready room as the next best option.
* We cannot accept requests for 
											specific buildings or classrooms except for faculty with disabilities.

										
Please remember that this is a request and not a guarantee. Rooms are scheduled 
											based on University scheduling guidelines. If we cannot schedule what you have 
											requested, we will schedule the next best thing.