*Required Fields

Contact Information    
*Instructor Phone:
*Instructor Email:
Check if Requestor Information is the same as Instructor Information otherwise complete the following:
*Requestor Name:
*Requestor Phone:
*Requestor Email:

Course Information    
*Course Title   *Semester:
Fall Semester
Spring Semester
Summer Session
*Course Number  
*Start Date Calendar Days of Week (Check all that apply):
M   Tu   W  Th 

*End Date Calendar
*Start Time AM PM   If class does NOT run weekly, please indicate all dates needed:
*End Time: AM PM  
Exclude Dates:  

Room Information    
  Class Origination Site and Location (e.g. Omaha MSC 3029 or Lincoln COD rm. 1221)
Distance Video Locations    
  Distance Site(s) (e.g. Gering Room A, Grand Island, KNY 360, SB B132)

Requested Services    
Archive Video Stream   
Live Video Stream       
Phone Bridge   
      Number of audio participants
ECHO Record       
College of Dentistry Only:
   Recording visible to students
   Recording hidden from students

Please review your information prior to submitting your request. You will not be able to modify this document once submitted.
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Form Updated 9/16/2014

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