Instructional Communications Systems

Videoconference Program Request Form

Use this form to request videoconference time for courses, programs and meetings. This is a request, only. You will be contacted to complete the scheduling of this program. You will receive a confirmation of your request after we confirm with each site you have requested. Please complete all information on this form.

A) General Information

* 1. Program Title:
* 2. Coordinator's Name:
* 3. Sponsoring Department:
* 4. Street Address:
* City: St: * Zip:
* 5. Phone:
* 6. FAX:
* 7. Email:
8a. Moderator/Instructor Name:
8b. Phone: 8c. Email:

B) Category:

1. Type of Program and sponsoring institution:

Instructional, for credit, UW Institutions

Instructional, non-credit, UW Institutions

Administrative meeting or in-service, UW Institutions

Administrative meeting or instructional, Wisconsin State Government

Administrative meeting or instructional, Other Government

Administrative meeting or instructional, Non-profit organization

Internet2 Commons MCU Request (UW Madison departments only)

C) Scheduling Information

* 1. How many sessions will this program require?
* 2. How long is each session, in hours (e.g. 1.5 hours)?

* 3. Requested Day(s) of the Week:

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Second Choice of Day(s):

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

* 4. Requested date(s) (please list all that apply to this program):

1st Choice:

2nd Choice:

* 5. Requested Times:

a. Starting at:

b. Ending at:

6. Exceptions (please list any dates or times when this program can not be held):

D) Videoconference Information

* 1. How will we make the connections for this conference (check all that apply):

ISDN

DS-3

Not sure; please contact me

Comments:

* 2. Is this a (check one):

Point to point, conference

both

Site #1:

Site #2:

Multi-point conference

all

http://www.uwex.edu/ics/video/video_sites.cfm

	Site Name	# of Attendees
Site #1:
Site #2:
Site #3:
Site #4:
Site #5:
Site #6:
Site #7:
Site #8:

If more than 8 sites are needed, please list the additional sites here:

* 3. This program originates at (location where instructor or moderator will be):

4. Equipment/technology needs for instructor or moderator (may not be available at all locations, extra charges may apply):

Document camera

VCR

Computer

Internet Connection

Lavaliere (lapel) microphone

5. Equipment/technology needs for participants (may not be available at all locations, extra charges may apply):

Document camera

VCR

Computer

Internet Connection

* 6. Would you like this program recorded?

Yes

* If you would like your program recorded, please choose from the following options:

DVD

Streamed file using an ICS-created url

E) Billing information

* 1.) How do you want this program billed?

Direct Charge

Fund/Acct/Unit/Div/Dept/Activity/Class Code

(for Internet2, type "Commons" - UW Madison only)

Invoice

Credit Card
(This is not a secure Web site. You will be contacted for credit card information following the receipt of this form)

2.) Account Information (if different from coordinator):

Billing Name:
Billing Department:
Billing Address:
Billing City, State, Zip:
Billing Phone Number:
Billing Email:

F) Misc:

Deadlines:

Remarks:

G) Request submitted by:

* 1. Name:
* 2. Email address:
* 3. Confirm Email address:
* 4. Phone Number:

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