Request for Assistive Technology Collaboration 2025-2026
 Sara Koenecke is the Prairie Lakes AEA Assistive Technology Coordinator. Please take a few minutes to complete this form that's designed to gather background information needed to serve the student and you. 
THIS IS NOT FOR DEVICE REQUEST. Device Requests are through Insignia at https://plnwaea.insigniails.com/Library/Login.  Your district AEA staff will assist you with device check-outs. 
Sign in to Google to save your progress. Learn more
Email *
What prompted this request?
What type of support is needed?
Clear selection
Date
Student Name
Date of Birth
Grade
Gender
Parent's name
School District
Name of school building and location *
Please list name of building and town which building resides
Case Manager
AEA Consultant
Case Manager's Email
Person Completing the Form
Goal Areas
Related Services
Medical History
Any other areas of concern
What goal areas are you requesting assistance for?
What other information do you feel is important for the AT team to know?
Which day of the week works best for the team? *
What time of the day works the best? *
What technology is available to the student? *
Required
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This form was created inside of Prairie Lakes AEA.

Does this form look suspicious? Report

Google Forms