KSSB Service Request
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**Note**: Assessments provided are consistent with recognized best practices in the field. While we aim to be responsive to all submissions, it is not always possible to provide assessments within a requested timeline. KSSB requests access to a student’s customary environment and input from local team members in order to complete an assessment that provides the district with useful information. Our consultants use consistent, thorough processes while exercising professional judgment at each step in the process.
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Today's Date *
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KSSB Logo
School District or Agency Name: *
Reason for Request *
Please provide specific reason for this request (assessment/consultation/observation/attend KSSB, etc).
Is this request related to an individual child/student? :
If you answer "Yes" you will need to provide details about the student.
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**PLEASE NOTE** These reports MUST be received before a KSSB Service Plan can be developed. (Current within 1 year)
Send to: blind-reports@kssdb.org

-IEP/IFSP
-Current Comprehensive Evaluation
-Medical records indicating vision diagnosis
-Ophthalmological/Optometric Examination Report
Additional reports - Please submit if available

Functional Vision Assessment
Learning Media Assessment
Orientation & Mobility Evaluation
Low Vision Evaluation
I understand services will not be provided until this information is received.
Student Legal First Name:
Student Legal Last Name:
Sex:
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Date of Birth:
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Primary Parent/Guardian
While a student may have multiple parents or guardians on file with the school, we need one to be designated as the primary for record keeping purposes.
Parent/Guardian First Name:
Parent/Guardian Last Name:
Home Address (include city and zip code)
Parent/Guardian Phone #:
Parent/Guardian Email:
Other Parent/Guardian
A secondary parent/guardian may be specified here. If additional parents/guardians need to be specified, they can be added to the child's/student's file at a later date.
Other Parent/Guardian Name and Address:
Other Parent/Guardian Phone #
Other Parent/Guardian Email
Is child/student registered with APH?
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Does child/student have a hearing loss? *
Is child/student on KS Deaf-Blind Registry? *
SPED Director/Program Coordinator: *
Name and email address of the person to whom invoices should be sent. *
This is often someone other than the SPED Director. This relates to those services for which there is a charge. Some services are free.
Contact Person: *
This is the person KSSB will contact regarding the request.
Position: *
Phone #: *
Email: *
Do you have a current service plan with KSSB? *
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