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Sample Manitoba Self-Declaration Form


Self-Declaration Form

Patron Information


Library Card Number:_____________________________________


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:________________________________________
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.

The forms provided on the NNELS website are sample documents which can be adapted to the local needs of libraries. Libraries are encouraged to brand the documents as per their library's standards and provide their respective contact information regarding the Collection Notice on the forms. User groups have identified that the Self-Declaration Form is a preferred method to gain access to the NNELS website and its accessible materials. It is a local decision whether libraries will require all, some or any of patrons requesting to use NNELS to fill out the Competent Authority Form. Once signed the Self-Declaration and Competent Authority forms will need to be filed and kept on location at your library for your records, as per the appropriate record retention and disposition schedule.

Hi Team NNELS Manitoba,

As you are developing and implementing your NNELS process internally, please work to ensure that the documents are accessible to persons with a print disability i.e. do not underline words or italicize words and be sure to use a Sans Serif font like Ariel size 14. If you have any additional questions regarding best practices to serve persons with a print disability don’t hesitate to contact me at (204)726-6218 or you can utilize the clear print available from The Accessible Campus: Accessible Digital Documents or Websites – Clear Print Guidelines.