E-Mail Completed Referral Form To

E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Assistive Technology Evaluation Referral Form

School District: School: Student’s Name: Date of Birth: Grade: Person Completing Form: Phone: Title: Best Time to Contact:

The student is experiencing difficulty accessing the curriculum in the following areas (check all that apply): Communication Handwriting: Writing speed Legibility Physical aspects of writing Other (please describe): Written Expression: Spelling Organization Other (please describe): Reading Organization Participating in inclusive settings Access to educational materials due to a physical disability: Computer Books Manipulatives Other (please describe): Other (please describe):

Are the areas checked above currently documented in the student’s IEP? Yes No

Would AT consultation services meet the student’s and/or district’s need instead of a more formal evaluation? Yes No (please explain below why an evaluation is needed)

Please describe what you hope the student will be able to do as a result of this evaluation:

of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach

Please describe the student’s disability and any relevant medical conditions:

Hearing: Does the student have a hearing impairment? Yes No

Vision:

Does the student have eyeglasses? Yes (does he/she wear them: Yes No) No

Does the student have a vision impairment? Yes No

Motor Skills: Does the student have physical limitations that impact learning ability Yes No If yes, describe below:

The student: walks independently uses a manual wheelchair walks with a mobility aid (walker, cane, etc.) uses a power wheelchair

Does the student use a special seating system in the classroom? Yes No, uses regular classroom chair and table If yes, describe below:

The student is able to use his/her hands to complete the following tasks (check all that apply): Right Hand Left Hand Needs Assistance Eat Drink Scribble Trace Copy Write Use a Computer Keyboard Use a Computer Mouse Hit a Switch

Does the student receive Occupational Therapy at school? Yes - Name of therapist: No

Does the student receive Physical Therapy at school?

of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Yes - Name of therapist: No

Academic Skills: The student is able to (check all that apply): Objects Photos Symbols Words Numbers Match Recognize Identify/Label

What is the student’s approximate reading level: (or not able to read)

of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Communication: The student currently communicates via (check all that apply): Voice / Verbal speech Quality: Intelligible Intelligible only to familiar listeners Unintelligible Vocalizations (describe below)

Sign Language (describe below)

Gestures (describe below)

Pointing Eye gaze Manual communication board or book Objects Photograph Picture symbols Tactile symbols Letters Words Picture Exchange Communication System (PECS) Communication device (provide name and/or description below)

No communication system is in place

Using the communication methods indicated above does the student (check all that apply): Attempt to communicate with others Respond to questions Ask for help Respond to commands Comment on what is going on around them Follow directions Make choices initiate/terminate activities

The student can understand: Single words Phrases Age-appropriate conversation One-step directions Multiple-step directions Does not appear to understand spoken words

Does the student understand more than he/she is able to express? Yes No Sometimes

Does the student receive Speech Therapy at school?

of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Yes - Name of therapist: No

Note: The student’s speech therapist must be an active participant in the assistive technology evaluation if communication is an area of concern.

Director of Special Education Signature: ______Date: ___ Note: A typed name will be accepted if form is submitted by DoSE via email