Request Services Form – Assistive Technology Initiative

This form is to request accessible text, accessible media (captioning), web accessibility evaluations, classroom technology/distance ed evaluations, ODS/CDE/Learning Services referrals, request technology training and to report physical and/or technology barriers. If you have other inquiries, please complete the Contact Us Form.

ATI Services

Required Field*

Name*
Email*
Phone Number
Mason Affiliation*
Reason for Request*
Reason for Request*
Reason for Request*
Registration Status*
Referral Date*
Month
Day
Year
For bulk requests (e.g., 2 or more files), please use the Accessible Media Bulk Request Form (Excel) and attach to an email to amp@gmu.edu.

For Kaltura users: If your videos are hosted on Kaltura, please tag each video being requested with “captions.” This ensures that the ATI staff can locate the correct videos corresponding to the request. Please submit all accessible media requests at least 7 days prior to the date needed.
Any Mason faculty and/or staff member can submit document requests. Priority is given to those faculty members who have a student with a documented print disability and is registered with Disability Services. All other requests will be determined on a case-by-case basis.

SUBMISSION REQUIREMENTS:

Before submitting your documents, the faculty/staff member must add the following:
- For Word documents
- For PPT presentations
- For PDF documents
Visit Accessibility Resource Videos and Creating Accessible Microsoft Office Documents on the ATI Website for additional guidance.

Turnaround Time: Please allow approximately 2 weeks to process your requests. Depending on the time of year, this timeline may be much shorter (e.g., several weeks after start of Fall/Spring semesters, Summer sessions).
Are you implementing a new website or web-based software application? Are you a faculty member using new technology in the classroom or your online course and need to know if it is going to be accessible to everyone? We can help!

Complete this form so that ATI staff can test it with commonly used assistive technology applications (i.e., screen reader software, screen magnification, voice recognition, etc.).
- Captioning
- Audio Description
Date Needed By (mm/dd/yyyy)*
Month
Day
Year
Instructor Name*
Course Name and Number (Please enter format i.e. SOCI 100-001 if available)*
College/School/Department*
Instructional Designer you are working with (if any)?*
Type of Request*
Semester
Material Title*
Are you the copyright holder of the material?
If No, who is the copyright holder? (Please provide as much contact information as possible.)
Length of media to be captioned (total minutes - if seconds round up)*
Format of media to be captioned*
Delivery of Media to ATI*
I confirm this material is legal and will be used for educational purposes*
Additional Information (i.e., links)
Responsibility Acknowledgement*
- I acknowledge that video(s) will be used for at least one year. Video(s) transcripts are the property of George Mason University and thus will only be used on GMU websites and/or in classrooms.
  ATI will provide the following:
  Copy of video transcript (text file only) completed to at least 98% accuracy.
  ATI will not edit transcripts unless egregious errors are identified (i.e., accuracy or timing of captions)
  Confirmation emails sent upon receipt of your submission for processing, at the completion of your request, and as-needed throughout the process
Requester Name*
Semester*
Is this an academic or non-academic request?*
PLEASE NOTE: Academic - Resource(s) intended to be used in the classroom.
Faculty member (if different than requester)
Instructional Designer you are working with (if any)?*
Course Name*
Type of Course*
Is this a publisher resource (e.g., Pearson MyLab, McGraw Hill Connect, MapleTA, etc.)?*
List Publisher Resource(s) below (max - 5):*

PLEASE NOTE: Click the '+' sign to add additional resources.
Additional Information (Re: Publisher Resource)*
Please provide as much information as possible about the publisher resource(s) that you plan to use (i.e., name of resource(s), type, intended use in classroom, how it can be accessed, etc.).
Is this an application (e.g., Piazza, VoiceThread, Wikis, Blogs, etc.) to be used outside of the LMS?*
List Application(s) below (max - 5):*

PLEASE NOTE: Click the '+' sign to add additional applications.
Additional Information (Re: External Applications)*
Please provide as much information as possible about the external application(s) that you plan to use (i.e., name of resource(s), type, intended use in classroom, how it can be accessed, etc.).
Is this a website (e.g., web-based article, blog, etc.)?*
List Website URLs below (max - 20 sites):*

PLEASE NOTE: Click the '+' sign to add additional URLs.
Unit/Department*
Is this a software application or website?*
Name of Software Application*
Additional Information (Re: Software Application)*
Please provide as much information as possible about the application(s) that you plan to implement (i.e., name of resource(s), type, intended use, how it can be accessed, etc.).
List Website URLs below (max - 5 sites):*

PLEASE NOTE: Click the '+' sign to add additional URLs.
Additional Information*
Please provide any additional information about the website(s) to be tested (i.e., content author, web developer, etc.).
Campus or Location of Barrier*
If Other, Please describe
Describe the access barrier and whether it is physical or technology based: (i.e. website accessibility, classroom technology, document accessibility, non-captioned videos, library access, etc.) Please be as detailed as possible and include any website links if applicable.*
Have you made any other contacts to try to rectify this problem?*
If yes, please provide the following information:
Name of person contacted:
Position:
Email:
Phone Number:
Additional Information
We appreciate you bringing this concern to our attention. Please select the Submit button and ATI will contact you shortly.
Referral Name (Name of Student or Employee being Referred)*
First Last
Referral Mason Affiliation*
G Number (include 'G' before number)*
Referral GMU Email Address*
Referral Phone (Cell)
Referral Phone (Home/Work)
Nature of Impairment (Please also discuss functional limitations, if any):*
Current Technology and Devices (Please select the technology and/or devices that the student/employee is currently using. Add additional descriptions in the Comments field below).*
- None
- Communication Aids (Proloquo2Go, Dynavox, Other devices)
- Organization Software (Inspiration Software, Evernote, Other)
- Amplification System
- Mobility Aids (Wheelchair, Walker, Cane)
- Text to Speech Software (Read & Write, Kurzweil, etc.)
- Computer- Mac
- Computer- PC
- Mobile Device (iPad, iPhone, Android, Kindle, Other)
- MS Office 2010/2013
- Voice Recognition (Dragon Naturally Speaking, Other)
- Screen Reading Software (JAWS, NVDA, Other)
- Magnification Software (Zoomtext, Windows Magnifier, Other)
- Adaptive Input (Trackball Mouse, Ergonomic Keyboard, Other)
- Recording Device (Smartpen, Digital Recorder)
- Other
Comments for Other Current Technology:
Accommodations student/employee is approved for:*
- Accessible Electronic Text (Books in Word, PDF or other accessible formats)
- Extended time for in class quizzes, tests and exams
- Use of a computer for writing
- Spelling
- Use of alternative testing accommodation for tests/quizzes using Scantron form
- Note-taking services
- Computer access during class
- Copies of lecture notes/outlines/PPT presentations
- Text to Speech Software (Read & Write, Kurzweil, etc.) -- used primarily by students with print impairments related to learning/cognitive challenges
- Screen Reading Software (i.e., JAWS, WindowEyes, etc.) -- used primarily by students with print impairments related to vision loss
- Tools/Supports to aid with eye fatigue, strain, etc. (e.g., built-in iOS, Mac, PC features. etc.)
- Audio recorded lectures (i.e., handheld digital recorder, Livescribe Smart Pen)
- Speech Recognition Software (i.e., Dragon Naturally Speaking)
- Use of a calculator for quantitatively based exams
- Use of personal FM system/remote captioning
- Other accommodations
Comments for Other Accommodations
Where will the student/employee be using this technology? (Classroom, workplace, outside the classroom, during testing, etc...please specify)*
Goals- What specifically would you like to gain from this evaluation?
Student Name*
Unit making accommodation request*
Date Submitted (Please Note: Minimum 2 Week Turnaround Time)*
Month
Day
Year
Semester*
Year*
Department/Course #*
Type of Material*
If Other, please describe:
Type of Format Requested (check all that apply)*
- Braille
- DAISY
- HTML
- MS Word
- Power Point
- PDF
- RTF
- Tactile Graphics
- TXT
Material Title*
Publisher*
ISBN*
Comments
Copyright Agreement*
- In accordance with the United States Copyright Law: Chapter 1 of Title 17, United States Code, Section 121: I agree to provide proof of purchase (receipt) for each textbook/material requested to be converted into electronic or alternate format.
Additional Notes:
- I understand the ATI is not able to cut and rebind rented books.
- Completed requests are scanned on a first come, first served basis.
- A confirmation email will be sent as orders are completed.
- The accessible format is for your educational use only and may not be reproduced.
- After selecting the submit button, please email any documents that you need converted as mentioned in this request to: ati@gmu.edu
Type of request?*
Please indicate the type of request you have:
1. 1. I have a student with a print disability that has an immediate need (i.e., Disability Accommodation)
2. 2. I simply need assistance developing accessible course content (i.e., Compliance)
3. 3. I am part of SOUPR or OCDI (operated through the Stearn's Center)
Number of Documents with this Request*
Document Type(s)- Select all that apply*
- Word
- PDF
- Power Point
- Tactile Graphic
- Other
Instructional Designer you are working with (if any)?*
If Other, please describe:
Date Needed By:*
Semester when documents will be used:*
To assist us with prioritizing document requests, please indicate the semester that you will use the documents.
Course Prefix - Course # (If Applicable- Example: EDAT - 521)*

If this request is not related to a particular course, please indicate the unit's name or acronym (e.g., Disability Services or DS).
Additional Information
File Upload (max - 20 files, 8MB per file)*
Drop files here or

Accepted file types: doc, docx, ppt, pptx, pdf, Max. file size: 8 MB, Max. files: 20.
Learning Services Staff Name*
Learning Services Staff Email*

Name and email of staff member making referral.
Referral Name (Name of Student Being Referred)*
Referral Email*
Referral Phone Number
Reason for Referral (Check all that apply)*
- Training on Read & Write by Texthelp
- Training on Scanning Stations to self-scan documents/textbooks
- Training on Note-taking/Organization mobile apps
- Other Technologies
If Other, Please Describe:
What technology does the student currently use? (Check all that apply)
- PC
- Mac
- iOS Device (iPhone/iPad)
- Android Device (Tablet, Smartphone)
- Other
What technology do you currently use? (Check all that apply)*
- PC
- Mac
- iOS Device (iPhone/iPad)
- Android Device (Tablet/Smartphone)
- Other
For Other, Please Describe:
Comments or Questions
College or School*
Course Name and Number (Please enter format i.e. SOCI 100-001 if available)*
Semester/Year course will be taught*
Responsibility Acknowledgement*
- I acknowledge that I will give ATI access to my course after receiving confirmation from an ATI staff member that my request has been received.
Comments or Questions
Phone
This field is for validation purposes and should be left unchanged.

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