Saturday, July 31, 2010

Application

Complete the following application, giving as much detailed information about the student as possible. Submitted applications will go to the IATP office to be reviewed and assigned to an Assistive Technology Practitioner (ATP). You will receive confirmation of receipt of your application in three business days.

If you need help completing the application, have any questions, or have not received a confirmation of the receipt of your application, please call Nora at 1-800-432-8324 or email Nora Jehn.



Type of Assessment*			Initial Assessment Follow-up Assessment



Student's Information				Parent's Information
Student's Name*				Parent's Name*
Date of Birth*				Email Address
Age*				Street Address*
Student's Grade*				City*
				State*
				Zip Code*


Applicant's Information Person Completing the Application

Name*
Email Address*
School Contact Information
Contact's Name*
Email Address*

Phone Number*
School Address
School Name*

Street Address*
City*
State*
Zip Code*

IEP Team Members
Team Member		Title		Email Address		Phone Number
















Additional Information about Student

Classroom Setting*					Home Regular Education Classroom Resource Room Self-contained Other
Classroom Setting*
Disability* Check all that apply					Autism Cognitive Impairment Developmental Delay Emotional/Behavioral Disability Hearing Impairment Learning Disability Orthopedic Impairment


					Severe Multiple Impairments Speech/Language Traumatic Brain Injury Vision Impairment
Current Related Services Received* Check all that apply					Behavioral Therapy Instructional Assistant Occupational Therapy Physical Therapy Speech Therapy Transportation Other
Current Related Services Received* Check all that apply

Medical Considerations* Check all that apply					Currently taking medication for

					Fatigues easily Has an allergy to


					Has degenerative medical condition Has digestive problems Has frequent ear infections Has frequent pain Has frequent respiratory infections Has multiple health problems History of seizures Other – Describe briefly


Assistive Technology Currently Used* Check all that apply					None Amplification Systems Augmentative Communication System Computer Access – Type

					Computer – Type


					Daily Living - Type

					Environmental Control Unit Low Tech Vision Aids Low Tech Writing Aids Manual Communication Board Manual Wheelchair Positioning and seating – Type

					Power Wheelchair Voice Recognition Word Prediction Other





		Describe the student’s interests and likes*



		What task (s) does the student need to do that is currently difficult or impossible, and for which assistive technology may be an option? In other words, please list your student's goals that may be helped through the use of assistive technology.*



		Please describe the assistive technology that has been previously tried, the length of time you tried each, and the outcome (how did it work, or why it did not work).*


Please complete all summaries that apply to your student

		Computer/Device Access Summary of Student’s Abilities and Concerns Related to Computer/Device Access


		Motor Aspects of Writing Summary of Student’s Abilities and Concerns Related to Writing


		Composing Written Material Summary of Student’s Abilities and Concerns Related to Composing Written Material


		Communication Summary of Student’s Abilities and Concerns Related to Communication


		Reading Summary of Student’s Abilities and Concerns Related to Reading


		Learning and Studying Summary of Student’s Abilities and Concerns Related to Learning and Studying


		Math Summary of Student’s Abilities and Concerns Related to Math


		Recreation and Leisure Summary of Student’s Abilities and Concerns Related to Recreation and Leisure


		Seating and Positioning Summary of Student’s Abilities and Concerns Related to Seating and Positioning


		Mobility Summary of Student’s Abilities and Concerns Related to Mobility


		Vision Summary of Student’s Abilities and Concerns Related to Vision


		Hearing Summary of Student’s Abilities and Concerns Related to Hearing


		Are there any behaviors (both positive and negative) that significantly impact the student’s performance?


		Are there significant factors about the student’s strengths, learning style, coping strategies or interests that the team should consider?


		Thank you for completing the Assistive Technology Technical Assistance Application. If you need any help or have any questions, please do not hesitate to contact Nora. She can be reached at the IATP, 800-432-8324 or (208) 885-3630.
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Application