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Request for Captioned Video Material

Please return to West Campus DSR (mailcode-0095) within two weeks of semester start

With adequate notice, DSR may be able to secure or produce a titled copy of the materials you intend to utilize.

Instructor Name

Instructor Email

Instructor Phone

Semester

Course

Campus

Building/Room

	Format (DVD, VHS, etc.)	Title	Length (min.)	Publisher	Projected Date of Use
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