University of Maryland Dental School - Lecture Capture Request Form

Please complete the following form and send your request at least 3 working days prior to the actual event.  When you click on the Send Form button, it will be sent to the appropriate personnel and we will be in touch with you if we have any questions regarding your request.

Current Date: «
Requested by (e.g. Dr. John Jones): «
School (if not Dental)
Department : «	-- Select from the following -- Select EPOD Orthodontics Periodontics Health Promotion and Policy Oral Maxillofacial Surgery Diagnostic Sciences Biomedical Sciences
Division (if applicable):
Contact Phone number «
Contact Email Address: «
Presenter name if different from above
Course name and id (e.g. REST 521 - Dental Implant): «
Lecture Topic &/or Title «
Lecture capture date: «
Time e.g. 8 - 10 AM «
Lecture capture location «
Save this lecture until «	End of Fall Semester End of Spring Semester End of Academic Year Other (enter date below)
Other Date
Capture video of presenter? «	[ Yes ] [ No ]
Video files associated with lecture?: «	[ Yes ] [ No ]
Podcasting (coming soon)?	[ Yes ] [ No ]
Simulcast	[ Yes ] [ No ]
Using own Windows laptop?	[ Yes ] [ No ]
Using own Mac laptop?	[ Yes ] [ No ]
Special Instructions
Fields marked with "«" are required.

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