Library Instruction Request Form - Libraries

Instruction Session Request Form

Dates Preferred, in Priority Order
Faculty name:
Department:
Telephone (Work)
Telephone (Home)
E-mail
Preferred contact method
Course Number and Course Name
Number of students
1.
2.
3.
4.
Hands-on activity requested?	YES NO
Instruction Time Requested (please indicate a.m. or p.m.)
Start Time
End Time
Brief Description Of Instruction Requested
Database	YES NO
If yes, please specify
Web Sources	YES NO
Reference Sources	YES NO
Journals	YES NO
Government Documents	YES NO
Other (please specify)
Brief description of assignment:
ADA
Do any of your students require ADA accomodations?	YES NO
If so, how many?
Please specify type of accomodations required: