TEC District Request for Assistive Technology Support
Please complete this form to initiate the process for an Assistive Technology Consultation or Evaluation. Please note: A contract will be provided to your Special Education Administrator. Once the contract is signed, we can begin providing services.
Name of Person completing form *
Your answer
Email Address of person completing form *
Your answer
Student Name *
NOTE: If request is for a general district or classroom consultation enter "Classroom" for student name.
Your answer
Student Birth Date
Is the student currently on an IEP or 504 Plan? *
NOTE: If student has a current IEP or 504 Plan, please be prepared to provide a copy to your Assistive Technology Consultant.
District *
Contact email for Special Education Administrator: *
Your answer
Would you like to request an Assistive Technology Evaluation or Consultation? *
Assistive Technology Evaluation: A formal request for an evaluation of Assistive Technology needs for an individual student. Requires consultation with Special Education Department, parent permission and will include Team meeting, classroom observations, direct intervention with student, formal report, implementation plan, trials with tools and follow-up visits. Assistive Technology Consult: This may be a consultation for use of technology tools for the entire class. It may include requests for ideas for specific students(s). It will include an implementation plan with suggestions and training in use of specific tools and follow up visits as necessary.
General Background Information
Please provide some general background information about the student and their strengths and challenges including any relevant medical information and/or Please forward a current 504 plan or IEP along with any other relevant evaluation reports.
Your answer
Reason for Referral. Please indicate all areas of concern. *
What specific tasks/challenges/IEP goals would you like to see addressed through the use of Assistive Technology?
Please Identify the specific tasks that student has been struggling with that you believe could be supported by the use of Assistive Technology tools. Identify any tools and strategies that have been tried in the past and describe the outcome.
Your answer
What technology tools are currently available in the classroom/school environment?
e.g.desktops, laptops, tablets, chrome books, iPads, smartboard, document camera, low-tech tools, communication devices, availability of projection, laptop carts, etc.
Your answer
What General and Assistive Technology tools have already been tried and what have been the results?
Share devices, software, apps, etc that have already been trailed with the student - What has worked? What has not worked? Why do you think this is so?
Your answer
If you had the right Assistive Technology tools in place, what would that look like?
Basically, what academic GOALS are you expecting to meet? What changes would you like to see? What "magic" are you hoping for?
Your answer
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