<p> E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Assistive Technology Evaluation Referral Form</p><p>School District: School: Student’s Name: Date of Birth: Grade: Person Completing Form: Phone: Title: Best Time to Contact: </p><p>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):</p><p>Are the areas checked above currently documented in the student’s IEP? Yes No</p><p>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)</p><p>Please describe what you hope the student will be able to do as a result of this evaluation:</p><p>Page 1 of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach</p><p>Please describe the student’s disability and any relevant medical conditions:</p><p>Hearing: Does the student have a hearing impairment? Yes No</p><p>Vision:</p><p>Does the student have eyeglasses? Yes (does he/she wear them: Yes No) No</p><p>Does the student have a vision impairment? Yes No</p><p>Motor Skills: Does the student have physical limitations that impact learning ability Yes No If yes, describe below:</p><p>The student: walks independently uses a manual wheelchair walks with a mobility aid (walker, cane, etc.) uses a power wheelchair</p><p>Does the student use a special seating system in the classroom? Yes No, uses regular classroom chair and table If yes, describe below:</p><p>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</p><p>Does the student receive Occupational Therapy at school? Yes - Name of therapist: No</p><p>Does the student receive Physical Therapy at school?</p><p>Page 2 of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Yes - Name of therapist: No</p><p>Academic Skills: The student is able to (check all that apply): Objects Photos Symbols Words Numbers Match Recognize Identify/Label</p><p>What is the student’s approximate reading level: (or not able to read)</p><p>Page 3 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)</p><p>Sign Language (describe below)</p><p>Gestures (describe below)</p><p>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)</p><p>No communication system is in place</p><p>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</p><p>The student can understand: Single words Phrases Age-appropriate conversation One-step directions Multiple-step directions Does not appear to understand spoken words</p><p>Does the student understand more than he/she is able to express? Yes No Sometimes</p><p>Does the student receive Speech Therapy at school?</p><p>Page 4 of 5 E-mail completed referral form to [email protected] Or fax to 859-442-7038 Attn. Barb Wietlisbach Yes - Name of therapist: No</p><p>Note: The student’s speech therapist must be an active participant in the assistive technology evaluation if communication is an area of concern.</p><p>Director of Special Education Signature: ______Date: ___ Note: A typed name will be accepted if form is submitted by DoSE via email </p><p>Page 5 of 5</p>