Distance Learning Class Request Form

*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:

*Course Number:

*Start Date: 

*End Date:

*Start Time AM PM

*End Time: AM PM

Exclude Dates:

Fall Semester
Spring Semester
Summer Session

Days of Week (Check all that apply):
M   Tu   W  Th 

If class does NOT run weekly, please indicate all dates needed:

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.
Type the text from the image into the space below.

Form last updated 04/09/18

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