WCBVI Outreach Virtual Assistance Request Form
If you would like any assistance in completing this form or have questions, please contact:
WCBVI Outreach Office Operations Associate
Phone: (608) 758-6148
Virtual Assistance Request Process Flowchart
Please note that after 3 follow up attempts within two weeks, we can consider the OSR closed and the requester needs to fill out another form.
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Name of Teacher of the Visually Impaired (TVI) and/or Orientation & Mobility Specialist (O&M)
Email of Teacher of the Visually Impaired (TVI) and/or Orientation & Mobility Specialist (O&M)
Name of Local Education Agency (LEA) or Special Education Director
Email of Local Education Agency (LEA) or Special Education Director
Training for Ages Birth to Three Years
Consultation for Ages Three to Six Years
School Age Consultation
Orientation & Mobility (O&M) Consultation
Assistive Technology Consultation
Virtual Mini Low Vision Clinic
Parent Liaison (Ages 0 through 12 years)
Parent Liaison (Ages 13 through 21 years)
Virtual Event Support (WCBVI Outreach will do our best to support virtual events based on current staffing)
Professional Development Needs
Give us a short summary of your needs.
Please keep your answer to 1-3 sentences only.
Opt in statement: by completing the student name section of this form, you state that you understand that student name is Personally Identifiable Information (PII). If you do not wish to share your students PII on this form, please leave a message with your name, the date of your request, and the student name for Outreach at (608) 758-6148.
How would you prefer to be contacted?
Zoom Meeting (a link will be sent to your email)
Best time to contact you:
Please list the contact information for your preferred method of contact (phone or email address).
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This form was created inside of Wisconsin Center for the Blind and Visually Impaired.