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Assistive Technology Request Form
Assistive Technology (AT) and Alternative Augmentative Communication (AAC) Request Form
Last, First Name of student
Your answer
Grade
Your answer
DOB *
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Date of Request *
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CST Case Manager *
School *
Therapist(s) involved
Your answer
Teacher (Last Name, First Name)
Your answer
Classification *
Your answer
Was AT Evaluation completed or are you requesting an informal Assistive Tech -Educational Technology Observation ? (if AT Eval has been completed, please send copy to Edison Sp Ed office) *
Date of AT Evaluation (if applicable)
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Requested AT (include Device/type, Apps) *
Your answer
Cost of request AT *
Your answer
What is the educational need for the AT or Apps? *
Your answer
What will the student be able to do with the AT that they cannot do now? *
Your answer
Has the student had any AT prior to this time? *
If yes (student had prior AT), please explain:
Your answer
Will TRAINING be required for the device/software/application?
If Training is required, who will be trained/by whom?
Your answer
Additional Comments
Your answer
AT Decision (Office use Only)
Your answer
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