Video Conference Request Form

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Integrated Media Systems & Services

Cleveland State University Video Conferencing Details:

Video Conference Test number: 204.89.239.13
Test Video System used: Polycom F/X (rev. 6.0.5)
Distance Learning Headend Phone: +1 216 687 5270
CSU Distance Learning Headend: Rhodes Tower, Michael Schwartz Library, RT 705

See IVDL Technical Information for more details regarding the equipment used, interoperability, testing and more.

*Indicates a required field.

Conference Information

*Conference Requestor:

*Date and required E.S.T. time of the conference:

*Number of attendees:

Which site will be initiating the call?

*Will your conference require the presentation of peripheral media?
(DVD/VCR, PC/Laptop, Document camera)

*Does this conference need to be recorded?

Yes No

Please provide any additional relevant conference information :

*Cleveland State University Requestor email address:

*Cleveland State University Requestor Phone No.:

Cleveland State University Requestor FAX No.:

Remote Site Conference Information

NOTE: It is the CSU conference requester's responsibility to provide this information.
Test calls/Conferences will not be scheduled without a completed conference request form and successful test call.

*Video conference system number:

*Video System Type:
(make, model )

Video Conference Room Phone number:

*Technical Contact Name:
(should be available to the far-side of the conference for the duration of the conference)

*Technical Contact Email:

*Technical Contact Phone Number/Cell Number:

*Number of Attendees:

Test Call Details

*Proposed Date and E.S.T. time for video test:

*Call Speed:

384K 512K 768K

Questions? Contact CSU Interactive Video Distance Learning at 1-216- 687-5270 or email m.r.hackett@csuohio.edu.

Mailing Address
Cleveland State University
Integrated Media Systems & Services
2121 Euclid Avenue, RT 807
Cleveland, OH 44115-2214

Campus Location
Rhodes Tower 807
2121 Euclid Avenue
Phone: 216.687.3855
Fax: 216.687.9293

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