Request for Assistive Technology Consideration

Student Name: School: Date:

Date of Birth: Grade: 3 Year Review Date:
Case Manager: CM Phone #/Ext #:
Compliance Facilitator: CF Phone #/ Ext#:
Teacher: Teacher Phone #/ Ext #:
Parents: Parents Phone # / Cell Phone #:

Area of Need: Describe any educational tasks you would like the student to be able to perform through the use of assistive technology
devices and/or services.
Task #1

Task #2

Task #3

Describe tools, accommodations, and strategies now being used. (e.g. audio books, behavior plan, scribe, etc.)
Tools/accommodations/strategie Outcome (Include Student’s Response) Describe Any Factors that May Have Affected
s the Outcome

Yes No
❑ ❑ Assistive Technology Chairperson has been contacted
Please attach, or write on the back, the student’s schedule to assist us in scheduling observations. Thank-you
Revised June 2010