Teachers College, Columbia University
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Office of Access and Services for Individuals with Disabilities
Alternative Format Text Request
525 West 120th Street, Box 105 General Office: (212) 678-3689
Zankel Hall, Room 301 Deaf & Hard of Hearing Services:
New York, NY 10027 V/TTY (212) 678-3853
Fax: (212) 678-3793
Please complete one form for each book requested
If you have not attached a copy of your course syllabus, we will not be able to process your request
Date of request
Date needed by_______________________________
While every attempt will be made to fulfill all requests for reasonable accommodations regardless of when these requests are made, making requests at least three weeks before the due date will ensure that accommodations will be provided.
Student name TC ID #
Semester/year Course # Instructor
Book Title_____________________________________________________________________
Author/Editor________________________________________ Copyright/Edition_________
Please indicate the alternative text format(s) you are able to access:
□ Tape (4-track or 2-track)
□ Text files (.txt) for screen-reader
□ Roadrunner
□ Daisy format (digital audio CD. Specialized portable CDROM player and/or
specialized software needed)
□ MP3 file on CD (specifically for computers & MP3 players)
□ Wave file (.wav) on CD (for computers & any CD player)
□ Large font
□ Other
Please remember to set up a time with our Adaptive Technology Specialist to discuss how to use the Adaptive Technology Lab and your alternative format texts!
By signing below, I hereby represent, warrant and covenant that: (1) I have purchased a print copy of the text listed above, (2) I have authorized the Office of Access and Services for Individuals with Disabilities at Teachers College to use my copy of the text to create a specialized format of the text exclusively for my use as an individual with a visual or print disability (3) I will use the specialized format of the text solely for my educational purposes at Teachers College, and (4), except as stated above, I will not sell, use, reproduce, copy or perform publicly the specialized format of the text.
Signature Date
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Book title
Author/editor Copyright/edition
ISBN Date needed by
................
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