Request for Assistive Technology Collaboration

STUDENT NAME BD______❐ M ❐ F STUDENT #

ATTENDING SCHOOL______PHONE ______RESIDENT SCHOOL ______GRADE Parent/Guardian/Surrogate/Adult Student Address______Telephone CASE MANAGER______Annual Review Date______Three Year Re-evaluation Date Speciality Designed Instruction: ❐ Reading ❐ Behavioral ❐ Vocational Education ❐ Math ❐ Physical Education ❐ Transition Services ❐ Written Language ❐ Communication ❐ Other Classroom Setting: ❐ Regular Education ❐ Resource Room ❐ Self Contained Approximate % of time______Approximate % of time______Approximate % of time______Current Related Services: ( Include Names) ❐ Counseling ❐ School Health ❐ Orientation/Mobility ❐ Physical Therapy ❐ Communication (speech/language) ❐ Interpreter ❐ Occupational Therapy ❐ Behavioral ❐ Autism Specialist ❐ Augmentative Communication ❐ Deaf/Hard of Hearing ❐ Vision Specialist

Medical Considerations: ❐ History of seizures ❐ Frequent pain ❐ Currently on medication for seizure control ❐ Frequent upper respiratory infections ❐ Degenerative medical conditions ❐ Digestive problems ❐ Multiple health problems ❐ Fatigues easily ❐ Frequent ear infections ❐ Other ❐ Current medications (describe if known)

Referrals in Process: ❐ PT ❐ OT ❐ Vision ❐ Hearing ❐ Augmentative Communication ❐ Autism ❐ Brain Injury Student Abilities: What does the student need to be able to do that he/she is not able to do as a result of the disability?

Describe the environment(s) in which the student may need assistive technology (i.e. regular ed classes, resources room, self-contained, library, play ground, lunch):

Assistance Request for Assistive Technology (Page 2) What interventions have been tried?

Assistive Technology Currently Used: ______General Info: 1. Does the student have behaviors (positive or negative) that significantly impact his/her performance?

2. Are there significant factors about this student’s strengths, learning style, coping strategies, or interests that the team should consider?

3. Are there any other significant factors about this student that the team should consider?

4. Please attach the current IEP. You may also want to attach student work samples that would be helpful for the committee to review.

SEND TO: Green Hills Area Education Agency Regional Assistive Technology Specialist

Assistive Technology

❐ Evaluation Assistance ❐ Equipment Trial - To be returned to Regional AT Specialist by ❐ Request for more information ❐ Other

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