Disability Services,
(423)439-8346/8370 (v/tdd)/(423)439-8489 (fax)
Name of Class:_____________________________ Day(s) of Week:___________ Time:_______________
Name of Class:_____________________________ Day(s) of Week:___________
Time:_______________
Name of Class:_____________________________ Day(s) of Week:___________ Time:_______________
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Interpreter: |
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SS#: |
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Address: |
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Student Name |
Date of Service |
Actual Time (i.e. 1-3:30 pm) |
Total Hours |
Fee Per Hour |
Total Due |
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Student Signature: |
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Interpreter Signature: |
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Date Signed: |
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S://studentaffairs/disability/share/forms/logsheet Interpreter and www.etsu.edu/students/disable/logsheet%20interpreter.htm
Revised 9/14/04