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Assistive Technology Request Form
Assistive Technology (AT) and Alternative Augmentative Communication (AAC) Request Form
* Required
Last, First Name of student
Your answer
Grade
Your answer
DOB
*
MM
/
DD
/
YYYY
Date of Request
*
MM
/
DD
/
YYYY
CST Case Manager
*
Choose
D Aliotta
C Barriale
C Berezansky
S Brosnick
S Burns
S Campbell
Y Connors
D Donnelly
J Fletcher
C Fogel
J Fucci
S Goldberg
C Lazar
A Meltzer
C Murphy
M Rothschild
M Russomanno
L Shinkar
D Tartaglia
V Wacha
T Walsh
S Zuckerman
J Freedman
OTHER
School
*
Choose
Edison
Forrest
Lyncrest
Milnes
Radburn
Warren Point
Westmoreland
MMS
TJMS
FLHS
OOD
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)
*
Yes, AT Eval completed (copy sent to Edison Sp Ed)
No, AT Eval not yet completed
Request AT/Ed Tech Observation
Date of AT Evaluation (if applicable)
MM
/
DD
/
YYYY
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?
*
YES
NO
Other:
If yes (student had prior AT), please explain:
Your answer
Will TRAINING be required for the device/software/application?
Yes
No
If Training is required, who will be trained/by whom?
Your answer
Additional Comments
Your answer
AT Decision (Office use Only)
Your answer
Submit
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