Communication Services Form (Faculty/Staff Request)
This form is for faculty and staff of Cerritos College that need to request communication
services for a deaf/hard-of-hearing person to participate in a campus activity such
as a counseling appointment, job interview, or class activity.
Please fill out this form completely. Each request must be filled-out separately (only one request per form).
Your E-mail Address:
Please select the appropriate service.
Need service for a ONE-TIME assignment
Need service for a new class for the semester
Cancel service ONE-TIME (list reason below in the comments section)
Cancel service for the whole semester (list reason below in comments section)
Please select the communication preference
Sign Language Interpreter
Assistive Listening Device
Please fill in ALL information in this section.
Please type in the class title or type of appointment: (Counseling, class etc.)
Select the appropriate day service will be needed or canceled
Mon Tue Wed Th Fri Sat Sun
Date of class/appt.:
Start Time: AM PM
End Time: AM PM
Location of class/appointment (building and room):
Name of student your class/appointment is with:
Comments/Additional Information: Please provide a description of the class/appt and include
the name of the counselor, instructor, etc. that the deaf/hoh person will be meeting
with. If this is a field trip request, please provide all the details about locations,