Assistive Technology Consult Request Form
Edmond Public Schools
Campus/School Name:
*
Date Submitted:
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Month
-
Day
Year
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Consult Requested by:
*
Relationship to Student:
*
Student Information:
Student Name:
*
First Name
Last Name
Date of Birth:
*
Please select a month
January
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Day
Please select a year
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Year
Current Grade:
*
Age:
*
Primary IDEA Category:
*
Please Select
Developmental Delay
Hearing Impairment (including deafness)
Speech and Language Impairment
Visual Impairment
Emotional Disturbance
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Deaf-Blindness
Multiple Disabilities
Autism
Traumatic Brain Injury
Intellectually Disabled
Gifted and Talented
Referred not Placed
Suspected IDEA Category if D.D.:
Please Select
Hearing Impairment (including deafness)
Speech and Language Impairment
Visual Impairment
Emotional Disturbance
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Deaf-Blindness
Multiple Disabilities
Autism
Traumatic Brain Injury
Intellectually Disabled
Gifted and Talented
Referred not Placed
Secondary IDEA Category (if applicable):
Please Select
Hearing Impairment (including deafness)
Speech and Language Impairment
Visual Impairment
Emotional Disturbance
Orthopedic Impairment
Other Health Impairment
Specific Learning Disability
Deaf-Blindness
Multiple Disabilities
Autism
Traumatic Brain Injury
Intellectually Disabled
Gifted and Talented
Referred not Placed
Medical Diagnosis(es):
*
Daily Schedule:
*
Unavailable Dates for Scheduling:
Current Educational Placement:
*
Has the student received an AT consultation before?
*
Please Select
Yes
No
Unsure
If yes, from whom and when?
If applicable, have you contacted your related service providers?
*
Please Select
Yes
No
Does not currently receive related services.
If yes, please describe input from related service providers:
Assistive Technology in Place or Tried with Student:
Brief description of student's abilities:
*
Describe any assistive technology currently being used.
*
Describe any assistive technology previously tried.
*
Primary Area(s) of Concern Related to AT:
1-Please check the primary area(s) of concern for the student related to assistive technology.
*
Please Select
Activity of Daily Living
Communication
Computer Access
Hearing
Mathematics
Mobility
Organization
Positioning & Seating
Reading
Rec/Leisure
Vision
Writing (Motor Aspects &/or Composition)
Other
1-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
*
1-Additional areas of concern?
*
Add another primary area of concern
Finished with primary area(s) of concern
2-Please check the primary area(s) of concern for the student related to assistive technology.
Please Select
Activity of Daily Living
Communication
Computer Access
Hearing
Mathematics
Mobility
Organization
Positioning & Seating
Reading
Rec/Leisure
Vision
Writing (Motor Aspects &/or Composition)
Other
2-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
2-Additional areas of concern?
Add another primary area of concern
Finished with primary area(s) of concern
3-Please check the primary area(s) of concern for the student related to assistive technology.
Please Select
Activity of Daily Living
Communication
Computer Access
Hearing
Mathematics
Mobility
Organization
Positioning & Seating
Reading
Rec/Leisure
Vision
Writing (Motor Aspects &/or Composition)
Other
3-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
3-Additional areas of concern?
Add another primary area of concern
Finished with primary area(s) of concern
4-Please check the primary area(s) of concern for the student related to assistive technology.
Please Select
Activity of Daily Living
Communication
Computer Access
Hearing
Mathematics
Mobility
Organization
Positioning & Seating
Reading
Rec/Leisure
Vision
Writing (Motor Aspects &/or Composition)
Other
4-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
4-Additional areas of concern?
Add another primary area of concern
Finished with primary area(s) of concern
5-Please check the primary area(s) of concern for the student related to assistive technology.
Please Select
Activity of Daily Living
Communication
Computer Access
Hearing
Mathematics
Mobility
Organization
Positioning & Seating
Reading
Rec/Leisure
Vision
Writing (Motor Aspects &/or Composition)
Other
5-List the specific task(s) you want the student to do that s/he is unable to do, at a level that reflects his/her skills & abilities.
Parent Information:
Parent Name (1):
*
First Name
Last Name
Parent Name (2):
First Name
Last Name
Phone Number (preferred):
*
-
Area Code
Phone Number
Phone Number (alternate):
-
Area Code
Phone Number
E-mail (Parent 1):
E-mail (Parent 2):
Primary Contact Information:
(Primary contact MUST be school personnel.)
Primary Contact Name:
*
First Name
Last Name
Primary Contact's Relationship to Student:
*
Phone (preferred):
*
-
Area Code
Phone Number
Phone (alternate):
-
Area Code
Phone Number
Preferred Time(s) to be Contacted:
Primary Contact's E-Mail:
*
By checking this box, you verify you have contacted the parent/guardian of the student to inform them that the Edmond Public Schools Assistive Technology Team may be contacting them to gather information regarding the student AND if deemed necessary, will complete an on-site assistive technology consultation.
*
Yes, I have contacted the student's guardian.
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