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Accessible Educational Materials Consultation Form
Email address *
Referring Staff Name *
Your answer
Staff Phone Number *
Your answer
Student Name *
Your answer
Student Age *
Your answer
Student Grade *
Your answer
Student Initials (First and Last) *
Your answer
Student's School District *
Your answer
Student's School *
Your answer
Student's School Address *
Your answer
What do you want the student to be able to do? *
Your answer
What do you hope to accomplish with this consultation? *
Your answer
What would be your anticipated next steps after this consultation? *
Your answer
Who is on your student's team? *
Required
Sensory and Physical Considerations
Does the student have... *
Yes
No
Unsure
Vision concerns
Hearing concerns
Orthopedic/Physical Access concerns
AAC or is minimally verbal
Vision concerns: if yes, describe:
Your answer
Has the student had a functional vision assessment? *
Has the student had a functional literacy assessment to determine their channel for literacy, including Braille? *
Physical access concerns: if yes, describe:
Your answer
Does the student use any equipment to help physical access, as it relates to their ability to use books or computers? Example: wheelchairs, switches, eye gaze, pointers, arm braces, hand/arm prosthesis, etc.
Your answer
Hearing concerns: if yes, describe:
Your answer
Has the student had a functional hearing assessment? *
Is the student’s primary or only language English? If not, describe:
Your answer
Can the student: *
Never
Seldom
Occasionally
Frequently
Always
Auditorily discriminates between sounds (early phonemic awareness)
Auditorily discriminates words/phrases
Selecting initial letter of word
Sight word recognition
Putting to symbols or words together to express an idea
Maintains fixation on stationary object
Scans line of symbols left to right
Visually recognizes people
Visuals recognizes common objects
Visually recognizes photographs
Visually recognizes symbols
Visually shifts vertically
Visually shifts horizontally
Looks to right and left without moving head
Scans matrix of symbols in a grid
Explores objects with hands
Explores objects with mouth
Do you suspect the student may need to access educational materials:
A copy of your responses will be emailed to the address you provided.
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