McBurney Disability Resource Center
Adaptive Technology Services Application (ATA Version)

Position(s) Applying For: / Adaptive Technology Services Assistant
Date:
Applicant Name:
Current UW Student?
Phone Number:
WISC Email Address:
Secondary Email Address:
Address:

EDUCATION & TRAINING BEYOND HIGH SCHOOL

Institution & Location / Dates Attended / Major, Subject, or Field of Study

Academic Info

Academic Info

Current UW-Madison status: (e.g. Freshman, Sophomore, Junior, Senior, Grad Student, Other)
Major(s):
Minor(s) or certificate program(s):
Current G.P.A. (include scale):
Anticipated graduation date (month & year):
If offered a position at McBurney, would you anticipate working until your graduation date?
If no, please explain when/why you would be unable to work (e.g., Fall 2018 semester abroad or fieldwork, etc.)

Interest Areas

Which of the possible primary service areas interest you the most? These positions will each have a primary service area within AT, but will be cross-trained in aspects of the other areas of AT.

Very Interested / Somewhat Interested / Not Interested / Need Additional Information / Notes: (Relevant experience, etc)
Post-production media captioning
Remote live captioning support
Document Conversion Service
Furniture accommodations
Other AT Support

Hardware/Software and Related Employment Info

Computer Hardware & Software Experience

(Please be specific, using descriptions, tasks, projects, skills, etc. to communicate your level of proficiency)

/ Experience and Comfort Level / Examples that Demonstrate Experience & Proficiency /
What is your experience and proficiency level using different type(s) of computers, mobile devices, and operating systems (Windows, Mac, tablets, smartphones, etc.)?
What is your experience and proficiency level using the following software/hardware (or equivalent):
Microsoft Word:
Microsoft Access or other database software:
Microsoft Excel:
Microsoft PowerPoint:
Internet web browsers (e.g. Internet Explorer, Safari, Firefox, Chrome, Edge):
Scanning/image editing:
Audio recording/editing/
compression:
Video recording/editing/ production/compression:
Media captioning:
Videography/photography:
Website design/programming:
Computer programming and scripting:
Adobe Captivate:
What other computer, technology and problem solving skills do you have that might be relevant to this position?

Related Employment Information

How many hours would you be available to work per week? / hours
to
hours
What is your preferred number of hours to work per week? / hours
to
hours
Are you available to work in January during winter break (between New Year’s and the start of classes)? How many hours per week?
Are you available to work during the summer? If so, how many hours per week?
Do you have a work-study award?
If so, what is the amount of your award? / $
What are the beginning and end dates of your work study eligibility? / m/d/yyyy:
to:
m/d/yyyy:
If hired, would you be combining this position with another job?
If yes, please provide the name of your employer:
Number of hours per week:

WORK EXPERIENCE

Please provide a work experience history, starting with your most recent job, internship, etc. Additional employer and experience information can be provided at the end of the application.

Employer 1:
Dates Worked:
City, State:
Your Duties:
Reason for leaving:
Employer 2:
Dates Worked:
City, State:
Your Duties:
Reason for leaving:
Employer 3:
Dates Worked:
City, State:
Your Duties:
Reason for leaving:

ADDITIONAL EDUCATION, TRAINING, EXPERIENCE

Note: Experience listed here does not have to be paid/employment experience. It can include volunteer, class-related, personal projects, etc.

Describe any education, training, or experience related to content areas that would enhance your ability to convert materials for classes that use specialized languages, symbols, or formatting (e.g. foreign languages, linguistics, math, science, music, art, computer programming, etc.)
Describe any education, training, or experience that would enhance your ability work with video, multimedia, and technology.
Describe any abilities or experience related to researching technical issues or processes on the web and then using that info to solve a problem or develop a new system/procedure.
This position works with materials from a variety of subject areas and departments across campus. Briefly describe the range of academic areas you have taken classes in or have experiences with, including any areas of particular expertise (e.g. foreign languages, linguistics, math, science, music, art, computer programming, medicine, architecture, etc.)
Describe any skills or experience with customer service, training others, creating training materials (online or in-person) and working directly with faculty/instructors.
Describe any background, education, training, or experience not already covered that you feel is relevant to this position (e.g., specific courses, in-service training, volunteer work):
Why does this job interest you?

Class Schedule & Availability

In the box below or as an attachment, please include your course grid for the current semester and (if available) the upcoming semester. (e.g if applying in late fall, include both Fall & Spring schedules)

Please indicate the days and hours you would be available for employment on or adjacent to the grid.

REFERENCES

Please list at least three references and provide information that will aid us in contacting these individuals (e.g. best way to contact them, and best days of week and time of day).

Please include at least one college/university professor/instructor if possible.

Reference 1

Name:
Company:
City, State:
Phone and/or Email:
Title & Relationship:
Notes:

Reference 2

Name:
Company:
City, State:
Phone and/or Email:
Title & Relationship:
Notes:

Reference 3

Name:
Company:
City, State:
Phone and/or Email:
Title & Relationship:
Notes:

Extra SPACE FOR Additional Information

Use this space if you wish to provide additional information or need extra space. Please make sure to note the section or question you are responding to.

Employer 4:
Dates Worked:
City, State:
Your Duties:
Reason for leaving:
Employer 5:
Dates Worked:
City, State:
Your Duties:
Reason for leaving:

McBurney Disability Resource Center

702 W Johnson St

Madison, WI 53715

www.mcburney.wisc.edu

(phone) 608-263-2741, (text messages) 608-225-7956, (fax) 608-265-2998

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