INFORMATION AND TRAINING REQUEST FORM

If you need help in completing this form, please contact the Disability Resource Center.

Section A: Customer Information

Name of Customer:
Operating administration:
Today's date:
Title:
Email address:
Phone/TTY: 						Fax:
Office mailing address (no post office boxes please)
Room number/Routing symbol:
Street address:
City: 					State: 					Zip:

Section B: Services Requested:

Information/Resources/Consultation (Please complete Section C) 
Presentation on DRC services (Please complete Section D)
Training on a specific topic or technology (Please complete Section D)

Section C: Information/Resources/Consultation

Please list your question(s):  




Section D: Training

Please check the topic(s) that you would like addressed in your training:  

Workplace Education 
Overview of Disability Resource Center services
Rights and responsibilities in employing persons with disabilities
Providing accessible services to persons with disabilities
Recruiting and hiring persons with disabilities
Other (please specify your interests and we'll do our best to meet your needs): 

Assistive Technology 
Overview of Section 508 of the Rehabilitation Act
Demonstration of assistive technology in the DRC Lab
The use of an assistive technology or accommodation device
Please specify the technology:
Using my office's software in conjunction with an assistive technology 
Please specify the technology:
Other (please specify your interests and we'll do our best to meet your needs): 

Logistical Information

Your audience will primarily include (please check all that apply):
Managers/Supervisors  
Recruiters  
Human resource professionals 
Employees -general audience
Employees with disabilities  
Other (please specify):
Estimated number of participants:  
Potential training date(s):
Length of training:  
Location:

To Be Completed By The Disability Resource Center Staff
Training Information

Materials/Handouts needed:

Videotapes needed:

A/V equipment needed:

Notes:











M-13, Room 2110
400 7th Street SW
Washington, DC  20590
Voice: (202) 493-0625, TTY: (202) 366-5273, Fax: (202) 366-3571
E-mail: drc@ost.dot.gov	    Web Site:  www.drc.dot.gov

Revised September 8, 2003