Self-Declaration Form

Patron Information

Name:_________________________________________________

Library Card Number:_____________________________________

Eligibility

The collection is for the use of persons with perceptual disabilities in accordance with the Canadian Copyright Act for material produced in alternative formats. A perceptual disability prevents or inhibits a person from reading conventional print. This includes:

• Severe or total impairment of sight or the inability to focus or move one’s eyes.
• The inability to hold or manipulate a book.
• An impairment relating to comprehension.

Agreement and Signature

I acknowledge that I have a perceptual disability as defined under the Copyright Act and that I may be called upon to provide proof of such disability from a competent authority.

In the case of a temporary perceptual disability, I am required to provide written notification to my public library when I am no longer limited by a perceptual disability from utilizing conventional print material. At such time I will no longer have access to the NNELS collection.

NNELS material is restricted to personal use only. I will not modify, distribute, repackage, transmit, sell or otherwise use copyright material which is inconsistent with the rights of copyright owners.

I acknowledge and agree to these terms and conditions.

Patron Signature:________________________________________
Date:__________________________________________________
Library Staff Member:_____________________________________

Collection Notice

The Canadian Copyright Act permits the production and sharing of accessible formats of original material if there is no existing accessible format available and only for persons with a perceptual disability. In accordance with subsection 36(1)(a) and (b) of the Freedom of Information and Protection of Privacy Act, the personal information collected on this form is used by the library for the purpose of satisfying the eligibility requirements for providing library patrons with access to the National Network for Equitable Library Service (NNELS) which contains the accessible format material. Your library card number will be shared with NNELS in order to facilitate direct access to their online library collection.

If you have any questions regarding the collection, use or disclosure of your personal information, please contact your local public library.