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:
              
              
          

          

            Course Reference Number (CRN): 
              
            
          

          

            Days:
                  
                  Mon   
                  
                  Tue  
                  
                  Wed  
                  
                  Thu   
                  
                  Fri
          

          

            Start Time:
              
              
                
                
                      End Time:
                
                
                
              
          

          

            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.