REGION 1A

REQUEST FOR ASSISTIVE TECHNOLOGY ASSISTANCE

AT Services:    Eval    Follow-up    Training □          Initialed by Sped Coor: ___________        

Student: ________________________                Initial AT Eval? Yes                 No

REED Date: ____________________                IEP Due Date (30 days): __________

(Only if this is an initial AT eval-Please attach REED)

IEP team members: (OT, SLP, PT, aide, gen. ed teacher, technology staff, transition coordinator)

_________________________________                __________________________________

_________________________________                __________________________________

_________________________________                __________________________________

IEP goals to be addressed with AT:         Tools or strategies tried or using now

 Mechanics of writing                ______________________________________________________

 composing written material        ___________________________________________

 Reading                        ___________________________________________

 Learning/studying                ___________________________________________

 Math                        ___________________________________________

 Computer access                         ___________________________________________

 Communication                       ___________________________________________

 Vision                               ___________________________________________

 Hearing                                       ___________________________________________

 Activities of Daily Living         ___________________________________________

 Vocational                               ___________________________________________

 Recreation/Leisure                      ___________________________________________