<p> Request for Assistive Technology Collaboration</p><p>STUDENT NAME BD______❐ M ❐ F STUDENT #</p><p>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</p><p>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) </p><p>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?</p><p>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):</p><p>Assistance Request for Assistive Technology (Page 2) What interventions have been tried?</p><p>Assistive Technology Currently Used: ______General Info: 1. Does the student have behaviors (positive or negative) that significantly impact his/her performance?</p><p>2. Are there significant factors about this student’s strengths, learning style, coping strategies, or interests that the team should consider?</p><p>3. Are there any other significant factors about this student that the team should consider?</p><p>4. Please attach the current IEP. You may also want to attach student work samples that would be helpful for the committee to review.</p><p>SEND TO: Green Hills Area Education Agency Regional Assistive Technology Specialist</p><p>Assistive Technology</p><p>❐ Evaluation Assistance ❐ Equipment Trial - To be returned to Regional AT Specialist by ❐ Request for more information ❐ Other </p><p>Comments:</p>