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Campus Accessibility/Interpreter Request Form

To request accessibility to a campus event, please complete the form below and press the “Submit Request” button at the bottom of the page. You will receive confirmation that your request has been received. If you have any questions, please e-mail DSInfo@colorado.edu or call (303) 492-8671.

PLEASE COMPLETE THIS FORM AS FULLY AS POSSIBLE. REQUESTS NEED TO BE RECEIVED NO LESS THAN 5 BUSINESS DAYS PRIOR TO THE EVENT.

Requester name

Requester phone (include area code) - - V/VP/TTY

Requester title

Requester e-mail

ACCOMMODATION REQUESTED (check all that apply)

• Materials in Alternate Format

	Braille
	Electronic Format
			PDF
			Word
			Other

• Communication Access

	Interpreting
	Real-time captioning
	FM System
			Personal
			Group (link)

• Physical Access (please refer to the Campus Accessibility Guide at www.colorado.edu/disabilityservices/accessguide.html)

Please describe:

EVENT

Date(s)	Day of the Week	Time: from - to
		to
		to
		to
		to

Type of Event (meeting, conference, lecture, etc.)

Event Location

Special Notes (agenda, meeting outline, guest speakers, etc.)

Event sponsor/department

Event contact person

Event contact phone (include area code) - -

Event contact e-mail

PARTICIPANT(S)

PAYMENT

Accessibility to campus-sponsored events may be paid for by the Chancellor’s Central Access Fund (CAF). All non-campus sponsored or revenue-generating events will be billed for these services If you have any questions as to whether your event will qualify for central access funds, please review the CAF guidelines.

If warranted, the cost for accessibility requests will be charged to a Speed Type and PeopleSoft number and we will contact your account representative. A copy of the transaction will be mailed to the account contact person for account reconciliation.

Account contact

E-mail address

Phone number - -

Department

Campus box number

FOR OFFICE USE ONLY

	NON-BILLABLE (Campus sponsored event; Non-revenue generating event)
	BILLABLE (Non-campus sponsored event; Revenue generating event)

Speed Type

PeopleSoft account # (such as 552605)

Revised 7/08