WCBVI Outreach Virtual Assistance Request Form
If you would like any assistance in completing this form or have questions, please contact:

Jacklynne Ramirez
WCBVI Outreach Office Operations Associate
Phone: (608) 758-6148
Email: jacklynne.ramirez@wcbvi.k12.wi.us

Virtual Assistance Request Process Flowchart
https://drive.google.com/file/d/1Cs188pYbVFyrQNDyJ40zE7uWpy8gqxCm/view?usp=sharing

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 *
Your Role: *
School District *
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 *
Services Requested: *
Required
Give us a short summary of your needs. *
Please keep your answer to 1-3 sentences only.
Student Name:
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? *
Best time to contact you:
Please list the contact information for your preferred method of contact (phone or email address). *
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