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Instruction Session Request Form

Faculty name:
Department:
Telephone (Work)
Telephone (Home)
E-mail
Preferred contact method
Course Number and Course Name
Number of students
Dates Preferred, in Priority Order
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 accommodations? YES NO
If so, how many?
Please specify type of accommodations required:



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