KSSB Service Request
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**Note**: Assessments provided are consistent with recognized best practices in the field. While we aim to be responsive to all submissions, it is not always possible to provide assessments within a requested timeline. KSSB requests access to a student’s customary environment and input from local team members in order to complete an assessment that provides the district with useful information. Our consultants use consistent, thorough processes while exercising professional judgment at each step in the process.

Today's Date *
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School District or Agency Name: *
Your answer
Reason for Request *
Provide specific services you are requesting (assessment/consultation/observation). Please note that placement at KSSB is a joint IEP team decision and is not covered by this form.
Your answer
Is this request related to an individual child/student? : *
If you answer "Yes" you will need to provide details about the child/student.
**PLEASE NOTE** These forms MUST be received before a KSSB Service Plan can be developed. (Current within 1 year)
Send to: blind-reports@kssdb.org

-IEP/IFSP
-Current Comprehensive Evaluation
-Medical records indicating vision diagnosis
-Ophthalmological/Optometrict Examination Report

Additional reports - Please submit if available

Functional Vision Assessment
Learning Media Assessment
Orientation & Mobility Evaluation
Low Vision Evaluation
I understand services will not be provided until this information is received. *
Required
Child/Student's Legal First Name: *
Your answer
Child/Student's Legal Last Name: *
Your answer
Sex: *
Date of Birth: *
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Primary Parent/Guardian Information
While a student may have multiple parents or guardians on file with the school, we need one to be designated as the primary for record keeping purposes.
Parent/Guardian First Name: *
Your answer
Parent/Guardian Last Name: *
Your answer
Home Address (include city and zip code) *
Your answer
Parent/Guardian Phone #: *
Your answer
Parent/Guardian Email:
Your answer
Additional Parent/Guardian Information
A secondary parent/guardian may be specified here. If additional parents/guardians need to be specified, they can be added to the child's/student's file at a later date.
Additional Parent/Guardian Name and Address:
Your answer
Additional Parent/Guardian Phone #
Your answer
Additional Parent/Guardian Email
Your answer
Is child/student registered with APH?
Does child/student have a hearing loss? *
Is child/student on KS Deaf-Blind Registry? *
SPED Director/Program Coord.: *
Your answer
Name and email address of the person to whom invoices should be sent.
This is often someone other than the SPED Director. This relates to those services for which there is a charge. Some services are free.
Your answer
Contact Person: *
This is the person the school will contact regarding the request.
Your answer
Position: *
Your answer
Phone #: *
Your answer
Email: *
Your answer
Do you have a current service contract with KSSB? *
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This form was created inside of Kansas Schools for the Deaf and the Blind.