LIU AT Lending Library Requests
Please complete this form to request an item from the LIU School-Aged Programs AT Lending Library. You MUST let the student's LEA representative know that you are requesting an item to trial from the lending library before making a request. Remember that the student's LEA is financially responsible for any purchased AT that is recommended for a student's IEP after a trial is complete.
Date of Request *
MM
/
DD
/
YYYY
Name of Requestor *
Your answer
Requestor's Position
Your answer
Requestor's Contact Information (Email, Phone Number) *
Your answer
Student Name (for whom the loan is being requested) *
Your answer
Student's Home District *
Your answer
Student's Building *
Your answer
What type of AT are you requesting (tab names on inventory sheet) *
Next
Never submit passwords through Google Forms.
This form was created inside of Lincoln Intermediate Unit 12. Report Abuse - Terms of Service