Log In Date ____________
DIVISION OF INSTRUCTION/SPECIAL POPULATIONS ADAPTIVE ASSISTIVE TECHNOLOGY
TECHNICAL ASSISTANCE REQUEST Please complete and sign all areas, save to your desktop, then file/attach to email:
[email protected] Local Education Agency__
__
Campus
_____
Address___________________________________________ Phone_________________________ Teacher______________________________ Student’s School Day Begins _______ Ends_______ Name of Student_____________________________ DOB____________ Age_______ Sex_______ Current Placement
_______ Grade___________________
Mark Eligibility Code (Primary & Secondary) AI AU DB ED ID LD MD
NCEC
OHI
Please indicate AT services requested: Augmentative Communication Assistive Computer Access Environmental Control Other (specify) Due Date of AT Request_______________
OI
SI
TBI
Switch Use/Adaptive Play
(Must give at least 20 calendar days’ notice)
Contact person for scheduling___________________________ Phone___________ Email:________________________________________
A check in this box and authorizing signature, indicates that all procedural Safeguards as stipulated in Rules and Regulation relative to student/parent rights have been implemented.
_______ Special Education Director
Date
THIS INFORMATION IS TO BE USED WITH PROFESSIONAL STAFF ONLY IN KEEPING WITH FERPA AND IDEA CONFIDENTIALITY REQUIREMENTS. It is the policy of Region 10 Education Service Center not to discriminate on the basis of race, color, national origin, gender or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972, and section 503 and 504 of the Rehabilitation Act of 1973, as amended Region 10 Service Center will take steps to ensure that lack of English language skills will not be a barrier to admission and participation in all educational programs and services. Revised Aug. 2013
Disability (Check all that apply.)
Speech/Language Significant Developmental Delay Cognitive Disability Other Health Impairment Traumatic Brain Injury Autism Emotional/Behavioral Disability Orthopedic Impairment – Type
Specific Learning Disability Hearing Impairment Vision Impairment
Classroom Setting
Regular Education Classroom Resource Room Self-contained Home Other _________________________ Current Services Received and Names
OT ___________________
PT ____________________ Speech _________________
Significant Medical Considerations (Check all that apply.)
History of seizures Fatigues easily Has degenerative medical condition Has frequent pain _____________________ ______________________________________ Has multiple health problems Has allergies to _________________________________________________________________ Currently taking medication for Other – Describe briefly
Assistive Technology Currently Used (Check all that apply.)
None Manual Communication Board Low Tech Vision Aids Environmental Control Unit/EADL Manual or Power Wheelchair Voice Recognition Adaptive Input - Describe Adaptive Output - Describe Other
Low Tech Writing Aids Augmentative Communication System Amplification System Computer – Type (platform)_____________ Word Prediction
THIS INFORMATION IS TO BE USED WITH PROFESSIONAL STAFF ONLY IN KEEPING WITH FERPA AND IDEA CONFIDENTIALITY REQUIREMENTS. It is the policy of Region 10 Education Service Center not to discriminate on the basis of race, color, national origin, gender or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972, and section 503 and 504 of the Rehabilitation Act of 1973, as amended Region 10 Service Center will take steps to ensure that lack of English language skills will not be a barrier to admission and participation in all educational programs and services. Revised Aug. 2013
Assistive Technology Tried Please describe any other assistive technology previously tried, length of trial, and outcome (how did it work or why didn’t it work.)
Assistive Technology Number and Dates of Trial(s) Comments: ____________________________________________________________________
___________________________________________________________________ ___________________________________________________________________ REFERRAL QUESTION What task(s) does the student need to do that is currently difficult or impossible, and for which assistive technology may be an option?
Based on the referral question, select the AT sections to be considered. (Check all that apply.)
Section 1 Section 2 Section 3 Section 4 Section 5 Section 6
Seating, Positioning and Mobility Communication Computer Access Motor Aspects of Writing Composition of Written Material Reading
Section 7 Mathematics Section 8 Organization Section 9 Recreation and Leisure Section 10 Vision Section 11 Hearing Section 12 General
PLEASE NOTE: THIS SERVICE MAY NOT BE USED TO SATISFY THE REQUEST FOR AN EVALUATION OR AN IEE. Please send request to: Adaptive Assistive Technology Program, Division of Instruction/Special Populations Region 10 ESC, 400 E. Spring Valley Rd., Richardson, TX 75081-1300 Fax: 972-348-1599 E-mail:
[email protected]
Region 10 ESC Program Coordinator Approval: __________________Date: ____________________
THIS INFORMATION IS TO BE USED WITH PROFESSIONAL STAFF ONLY IN KEEPING WITH FERPA AND IDEA CONFIDENTIALITY REQUIREMENTS. It is the policy of Region 10 Education Service Center not to discriminate on the basis of race, color, national origin, gender or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972, and section 503 and 504 of the Rehabilitation Act of 1973, as amended Region 10 Service Center will take steps to ensure that lack of English language skills will not be a barrier to admission and participation in all educational programs and services. Revised Aug. 2013
