Statement of Responsibility

Texas Department of State Health Services Audiovisual Library
Toll free: 1-888-963-7111 ext. 7260, 512-776-7260, Fax: 512-776-7474, E-mail 

Postal Service Mailing Address:
Audiovisual Library, MC 1975
Texas Department of State Health Services
P.O. Box 149347
Austin, TX 78714-9347

UPS/FedEx Mailing Address:
Audiovisual Library, Mail Code 1975
Texas Department of State Health Services
1100 West 49th Street, Warehouse Bldg., Rm. 116 
Austin, TX 78756-3199

Materials in the Texas Department of State Health Services Audiovisual Library collection are inventoried state property. The person indicated on the media order blank as the Borrower assumes all responsibility for borrowed media. Borrower responsibility includes:

1. Prompt return of materials by the scheduled date. The borrower is responsible for return shipping costs. Any borrower having three (3) late returns will have their Audiovisual Library privileges suspended. No further confirmed orders will be shipped to borrowers with materials still out that are two weeks or more late being returned. Willful failure to return borrowed media upon request will be viewed as theft of state property in violation of Section 31.03, Texas Penal Code, the conviction of which could, depending on the value, result in a fine not to exceed $500 (Class C Misdemeanor), to confinement up to 10 years and a fine up to $10,000 (Third Degree Felony). Please return materials by U.S. Mail, UPS, or other insured carrier.

2. Prompt pickup of scheduled materials by borrowers. Scheduled materials not picked up on the pickup date will be returned to the Library on that date and will be charged the same as a late return.

3. Replacement of lost or damaged materials. Audiovisual Library personnel check all materials for damage after each use. Materials returned by mail should be insured. Unless otherwise specified, insure each VHS video or DVD for $200; each model for $100; and each book, CD-ROM, or audio CD for $25. Shipments valued at over $400 should be returned by UPS or similar courier service. Borrowers will be liable for returned uninsured shipments lost in transit. In the event of loss or damage beyond repair, the Audiovisual Library will invoice the borrower for the full replacement value of the materials or the cost of the repair expense. All materials that come in the shipment must be returned, including study guides and video or audio cases or borrowers will be billed for their replacement. A packing slip or card is enclosed with each shipment. This should be completed with the number of showings and viewers for each audiovisual item borrowed.

4. Copyright compliance. Borrowed materials cannot be duplicated or televised without prior written permission from the copyright owner. Audiovisuals cannot be shown for commercial purposes, nor can an attendance fee be charged for their showing. Violations of federal copyright law will result in the immediate suspension of Audiovisual Library borrowing privileges and prosecution by the copyright owner can result in financial penalties and/or jail.

5. Preview prior to showing. Borrowers are responsible for selecting media appropriate for their audiences. Media should be previewed prior to showing.

6. Privacy notification. With few exceptions, you have the right to request and be informed about information that the State of Texas collects about you. You are entitled to receive and review the information upon request. You also have the right to ask the state agency to correct any information that is determined to be incorrect. See for more information about privacy notification. (Reference: Government Code, Section 552.021, 552.023, 559.003, and 559.004)

I acknowledge financial responsibility to the State of Texas should items borrowed be lost, stolen, or damaged from the date I receive the items until the materials have been received in the Library. I have read and agree to the terms in the Statement of Responsibility above.

Printed Name                                                                                         Fax No.

Organization                                               Business Phone                    Home Phone

Address                                                     City                                 County                    Zip

Signature                                                   E-mail Address                                             Date


Please check any/all that apply to you or your organization

Department of Assistive and Rehabilitative Services Library

Early Childhood Intervention ______                           Rehabilitation Services _____  

    ___ ECI: Family
    ___ ECI: Program
    ___ECI: State
    ___Child Care Provider
    ___Early Head Start
    ___Rehabilitation Practitioner
    ___Person, Family or Friend with Disability
    ___Other Agency           

Department of State Health Services Library

     ___Public School
     ___Private School
     ___Other Educational Group
     ___Church and Religious Organization
     ___Community and Civic Group
     ___Dept of State Health Services Employee (including regional offices and hospitals)
     ___Local Health Department
     ___Nursing Home
     ___Mental Health/Substance Abuse Organization
     ___Misc. Medical Group/EMS/Physician/Dentist/Home Health, etc.
     ___Prison/Detention Center
     ___Law Enforcement Agency
     ___Fire Department
     ___Other State Agency (Not DSHS or DARS)
     ___Federal Government
     ___County Government/ Other Regional Agencies
     ___City Government
     ___Private Business and Industry

Please complete and fax this form to the Audiovisual Library at 512-776-7474.

Last updated March 1, 2021