FNESC/FNSA Special Education
#113 – 100 Park Royal South
West Vancouver, BC
V7T 1A2
P: 604-925-6087
Toll Free: 1-877-422-3672
Fax: 604-925-6097
FNESC/FNSA Special Education Program (SEP) services are led by a multidisciplinary team whose mandate is to provide educational support services to students with special needs in BC
First Nations schools.
What educational support services are available?
SEP staff are available to travel to schools, given time and resource availability, to provide onsite support to help meet the needs of students. Supports include:

Assessment

Consultation

Intervention

Assistive Technology

Inclusion

Transition planning

In-service
Who Provides SEP Services in Schools?
The SEP Team consists of SEP Managers Holly Smith (Northern BC) and Madeline Price
(Southern BC), SEP Coaches, Speech Language Pathologists, Psychologists, and a SET-BC
Assistive Technology Consultant.
What resources are available on the SEP Website?
Additional information is available at www.fnsa.ca and www.fnesc.ca, including the SEP forms required for accessing services and funding.
Who are the FNESC Office SEP contacts?
Barb O’Neill, Senior Administrative Assistant
Tel (604) 925-6087 Fax (604) 925-6097
Holly Smith SEP hollys@fnesc.ca
or Toll Free 1-855-250-5083

School Request Form for FNESC/FNSA SEP Services
If you require FNESC/FNSA SEP services, please complete the School Request Form, ensuring you check off all of the services you are requesting and the service forms you will be submitting. Once this School Request Form and the relevant service referral forms are completed, please forward to
FNESC office prior to May 29, 2015.
Speech Language Pathology (SLP) Services
The SLP service delivery model is as follows.
 Schools can submit applications for SLP services.
 Applications will be reviewed based upon the students’ speech language needs.
 For applications that are accepted, support will be provided in one of two ways: o A FNESC employed SLP will visit schools that cannot access an SLP on their own; or o For schools that can access a SLP locally, SEP funding will be provided to reimburse schools for the SLP services, using the established FNESC SLP payment rate.
To request this support, applicants must complete the SLP referral checklist for each relevant student, along with a signed parental authorization for release of information form. The parental authorization for release of information forms MUST be signed in order for any student to be considered for service/funding.
Psycho-Educational Assessments
If you wish to refer a student for a psycho-educational assessment, please review the Guidelines for
Psycho-Educational Assessment Referrals prior to applying. If a student is eligible, fill out the
Psycho-educational Assessment form, along with the Parent/Guardian Authorization for Release of
Information for each student you are referring. Also include any relevant supporting documentation (i.e. psychological/psychometric, speech-language, vision, hearing, achievement/academic, Occupational Therapy assessments, SMART Goals, etc.). Current students who have been approved for the High Cost Additional Funding and who require re-assessment will be considered first priority.
SET-BC Assistive Technology
Please note there are significant changes in SET BC service delivery model for the 2015-16 school year. No students will be carried forward on the services list from 2014-15. Only very few students with complex needs will be considered for individual solutions at the Tier 3 level. Please attend a webinar on May 13 th at 10:00 am on the new service delivery model. Topics will include; determining if students meet individual criteria and opportunities for classroom based projects. If a student meets the new criteria for SET-BC services, please fill out the SET-BC forms.
School Special Education Support Services
If you require further information, or if you need to schedule special education support services such intervention planning, Individual Education Plan (IEP) development, DIBELS training, etc., please contact the SEP Manager in your area.
When all forms are complete, please scan and return them to
Barb O’Neill at barbo@fnesc.ca
or mail them to the FNESC office.
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This document is meant to provide some guidelines to help the schools decide which children should be referred for Psycho-Educational assessments.
What is a psycho-educational assessment?
There are different types of psychological assessments that employ a variety of techniques aimed at better understanding each particular individual’s needs. The assessments are designed to respond to the referral question, so the types of assessment procedures chosen by the psychologist are determined by the perceived problem.
 Most psycho-educational assessments are conducted with school-aged children, in response to referrals about problems that the child is experiencing.
 Most psycho-educational assessments explore multiple domains, including: o Cognitive and academic functioning o Language and communication o Long term and working memory o Attention and activity level o Executive functioning/self-regulation o Adaptive functioning/life skills o Social development and emotional functioning o Visual-perceptual/motor/sensory functioning
 In order to explore all of these domains, the psychologist normally gathers information from
multiple sources, such as direct testing (cognitive, academic, memory, language, etc.), observations (in class, during testing, on the playground), interviews (parents, teachers), rating scales (adaptive skills, executive functioning, behaviour), work samples, report cards, anecdotal reports, etc.
 Once psychologists have collected sufficient information about the child, they will hold a
debrief meeting with parents, teachers, administrators, educational assistants, and other professionals who work with the child (e.g., pediatrician, speech-language pathologist, occupational therapist, counsellor). These meetings will result in a productive sharing of ideas, further information sharing with the psychologist, as well as discussion of applicable diagnoses and recommendations for supporting the student at school and at home.
 The psychologist completes the assessment with a written report, copies of which are sent to the people who need them, including the school, parents, and outside agencies if consent is provided by the legal guardian. These reports are confidential and are to be kept safely in locked cabinets at school, with access provided only to individuals who need the information to support the student.
The psycho-educational assessment report is meant to be helpful for the child. The recommendations are generally geared toward supporting students at school, and should be in keeping with the guidelines for special education support established by each school.
 The psychologist will make diagnostic statements that either confirm or rule out whether the child meets the criteria for various types of support. This includes the Ministry of Education criteria for a special education category, the Diagnostic and Statistical Manual of Mental
Disorders (DSM) criteria for a disorder, and/or the FNESC/FNSA/AANDC guidelines for
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support. They may include statements about other types of support that could be available to the student, either immediately or in the future, such as Ministry of Children and Family
Development’s (MCFD) Children and Youth with Special Needs, Community Living BC, Fetal
Alcohol Spectrum Disorder (FASD) Keyworker, Provincial Outreach Program for Autism and
Related Disorders (POPARD) support for Autism Spectrum, etc.
What are potential benefits of an assessment?
 Better understanding: The main goal of the assessment is always to provide the child’s team with ways to support them in school. The assessment should reveal information that was previously not known about the child, so that everyone has a better understanding of the child as a learner, and to help the team to make adjustments to better suit the child’s differences. A diagnosis of a disorder or special need may be made.
 Extra supports: If a child is found to meet the criteria for any special needs classifications, the student may have access to additional support, including potential additional funding. For students who transition to a public school, access to services may depend upon meeting the criteria for Ministry of Education classification. This is one reason why psychologists attempt to determine if the student would meet those criteria.
 Outside Services: Similarly, there are services provided by outside agencies that are only available to individuals who carry diagnoses. Students who are eligible for extra services, for which a psychology assessment is a significant part of the classification process, include those who have: o Intellectual Disabilities (IQ and Adaptive Functioning below 70), o Learning Disabilities (IQ is average or higher, academic skills significant delayed) o Gifted (high IQ, or other evidence of exceptionally high potential) o Autism Spectrum Disorder (must be diagnosed by ICAAN assessment team, but can include the information provided by our psychologists) o Chronic Health Impairment (includes Fetal Alcohol Spectrum Disorder, which must be diagnosed by a team including a psychologist) o Students requiring Moderate or Intensive Behaviour Support and/or Mental Illness
(psychology assessments form part of the designation criteria)
Which students should be assessed, and timing of assessment?
Students of any age can receive a psycho-educational assessment, although FNESC will only fund the assessments for students up to 21 years of age, and usually after the child has received significant levels of intervention in the early grades.
 Primary: Assessments for children in the early grades can be appropriate, if the student appears to be meeting one of the following key categories. o If a child seems to have intellectual disability, they could be referred for psychoeducational assessment early (grade one or two). o If the child presents autistic-like characteristics, he/she should be referred to a family doctor and/or paediatrician to begin the process of the BC Autism Assessment Network
(BCAAN) multidisciplinary assessment, which can often take a minimum of one to two years. A psycho-educational assessment could be helpful in supporting the referral for the
BCAAN team, and sometimes reduces the wait time, but it is not necessary for a diagnosis.
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 Intermediate: Students in grades 3 to 8 are the most frequently referred and assessed. o If the child presents with delays in reading, writing and/or math, but seems to have sufficient intelligence to understand everyday materials, he or she may have a learning
disability (LD). Such children usually should be referred only after they have been provided with sufficient intensive interventions. o Students with persistent “behaviour” problems should have assessments to rule out learning problems as a cause of their challenging behaviour.
 Secondary: o Students who present with LD (either previously diagnosed or suspected) should be referred for an updated assessment prior to the provincial exams beginning in grade 10 to ensure that they qualify for adjudication adaptations, including a reader, scribe, technology, or extra time. o The assessment in the secondary school years can also support an LD student’s application for similar adaptations and support in post-secondary institutions for five years after the assessment is completed. o Students diagnosed with Intellectual Disability can be eligible for services from Children and Youth with Special Needs, a branch of MCFD, until they reach 19 years of age, and then from Community Living BC. The Ministry responsible for CLBC is now requiring the schools to confirm a diagnosis meeting the DSM-IV-TR criteria for “Mental Retardation” and/or
DSM-5 criteria for “Intellectual Disability” by the time the student is 16 years of age. This
Adults:
“confirmation” may require an updated psycho-educational assessment, depending upon the time since the previous assessment, and/or the confidence with which the previous diagnosis was made.
Assessments for adults can be appropriate if they have never been previously assessed and may be entitled to support if they were to receive a diagnosis. The main areas of support available to adults includes Community Living BC, which provides considerable funding and support for adults with
Intellectual Disabilities. FASD Keyworkers and CLBC supports are also available to students carrying a diagnosis of FASD.
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School: ______________________________________________________________________
Principal: _________________________________Email: ______________________________
SEP Contact _______________________________ Email: ______________________________
Address: ________________________________ Town: _______________________________
Postal Code: ___________________________
Phone: ________________________________ FAX: _________________________________
Request for Service

Psycho Educational Assessments (Psych Ed)

SET-BC Assistive Technology
For Speech Language Service Request Please check ONLY one box:

FNESC Speech Language Service (SLP) OR

Speech Language Funding Assistance, SLP Name: ________________________________
Number of students referred last year______
Number of new referrals ______
Please complete an application form for new referrals only.
This form, along with the following documents, completes the request package (please
ONLY include and check off forms for the services you are applying for)

Speech Language Pathology (SLP) Service School Request Form

Speech Language Pathology (SLP) Student Information Form

SLP Parent/Guardian Authorization for Release of Information

Psycho-educational Assessment Request Form

Parent Authorization for Psychological Assessment

SET-BC Referral Form

SET-BC Parent/Guardian Authorization for Release of Information
Name of person filling out the Form: (please print) __________________________________
Principal (or designate) Signature: ________________________Date: ___________________
Return to: Barb O’Neill, Special Education Program
FNESC/FNSA INFORMATION ONLY – DO NOT Complete
DATE RECEIVED: _______________________________ DATE LETTER SENT: ________________
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SCHOOL: …………………………………………………….. Date of Referral: ……………………
STUDENT’S NAME: ………………………………………… Date of birth: …………………….….
Date of IEP: …………………………………………..……… Current Grade: …..………………..
Previous assessments completed / date:
☐ Vision: ………………….. ☐ Hearing: ……………………..
☐ Psychology: …………………..…..… ☐ Speech-Language Pathology: ……..…….………..…
☐ Occupational Therapy: ..……..….… ☐ Academic Achievement: ………………...…..…..……
What concerns do you have about this student’s speech, language and communication skills?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________’
What information do you hope a SLP assessment will provide?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Person completing form: ____________________________________________ Title: ___________________________________________
Signature: _____________________________________________________ Date: ____________________________________________________
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Student Name: ___________________________________
Date of Birth: ____________________________________
I understand that an application is being made to the First Nations Education Steering
Committee (FNESC) and First Nations Schools Association (FNSA) for Speech Language
Pathology services for my child. As part of that application, I understand that the School,
________________________, must provide information about my child to FNESC and FNSA for evaluation. That information may include information about my child’s special needs, medical and educational history, Individual Education Plan, testing and assessment results and similar information. I understand that the information will be used by FNESC and the FNSA for the purposes of making a decision about providing additional funding for services for my child. I understand why I have been asked to release information and am aware of the risks or benefits of consenting or refusing to consent to release this information. I understand that all information will be treated as confidential by FNESC and FNSA, but that it will be disclosed within FNESC and FNSA to those individuals who are considering the funding application. I also understand that I may revoke this consent at any time by submitting a written revocation document to
FNESC. I understand that if I do not consent to the release of this information my child may not receive the support services that would be funded by this application.
□ Yes □ No I authorize release of school records to FNESC and the FNSA, including the records described above, concerning my child for the purpose of my child’s school applying for
Speech Language Pathology Services/resources for the above. The records should be directed to:
Special Education Program,
First Nation Education Steering Committee &
First Nations Schools Association
#113 – 100 Park Royal South
West Vancouver, BC, V7T 1A2
Tel (604) 925-6087
Fax (604) 925-6097
Signature of Parent/Guardian: ________________________________________
Name of Parent/Guardian (please print): ________________________________
Date: ____________________________________
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SCHOOL: …………………………………………….. Date of referral: ……………………
STUDENT’S NAME: ………………………………… Date of birth: …….………………...
Parents/Guardians:
………….……………………… Telephone: …………………………
Classroom Teacher: ………………………………… Current Grade: …………..………..
Attach previous assessments that have been completed, with date:
☐ Psychology:
………………….…… ☐ Speech-Language Pathology:
…………..……
☐ Occupational Therapy: ..………… ☐ Academic Achievement: …..………………….
☐ Vision: …………..…….. ☐ Hearing: ………..………... ☐ Other: ……………..……..
Reason for Referral: What are the major concerns, questions about this child?
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
How long/often has this student been having these difficulties?
………………………………………………………………………………………………………
Describe the types and frequency of interventions/supports that you are using to support the child (e.g. small group, visual schedules, pre-teaching before the lesson, double dosing core programs, school counsellor, social stories, etc.)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Child's learning style: (activity level, attention, organization, impulsiveness)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
S tudent’s personal characteristics, health or home background:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
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C hild’s behaviour:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
C hild’s attendance over the past few years (approx.%):
………………………………………………………………………………………………………
Describe the child’s academic development/performance:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Child's fine and gross motor skills compared to age expectations:
………………………………………………………………………………………………………
Child's speech and language skills compared to age expectations:
………………………………………………………………………………………………………
Child ’s special interests or talents:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Describe his/her social interaction with other children and with adults:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Parent/school relationship: (Are parents involved, concerned, aware of difficulties?)
………………………………………………………………………………………………………
………………………………………………………………………………………………………
Any Medical conditions/Medications:
………………………………………………………………………………………………………
Additional Comments:
………………………………………………………………………………………………………
………………………………………………………………………………………………………
………………………………………………………………………………………………………
***Note: Please submit any SMART goals developed for child along with this form***
Thank you for your caring support for this student!
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After consideration by the school team and in consultation with you, it has been determined that a psycho-educational assessment would be beneficial in supporting your child;
______________________________________ at _______________________________ School.
Purpose of Assessment
The main purpose of assessments is to help teachers and parents best support the student in school.
Assessment Process
The psycho-educational assessment may include:

Information from parent or guardian.

Observations conducted by school personnel on ability, achievement, behaviour and attendance.

Testing by a qualified school psychologist, which may include measures of: Intellectual
Ability, School Achievement, Perceptual Abilities, Adaptive Functioning (i.e., life skills),
Behaviour (i.e., attention, self-concept, social and/or emotional functioning)
If you have any questions about the psycho-educational assessment, you may contact Dr.
Leonard Stanley, Coordinator at 250 752-5423 or email - lenkz@shaw .ca
Outcomes
Following the assessment, the psychologist will discuss the findings and recommendations with the parents and relevant school staff. The psychologist will write a report, and copies will be provided to the parents/guardians and put in the student's school file.
For some students, assessment findings may assist in identifying various learning difficulties as referenced in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition. If a student meets criteria as a student having special needs, additional services may be recommended.
Voluntary Consent
1.
Consent for Referral - The school would like your consent to refer your child for assessment to FNESC – Special Education. The FNESC special education team will determine if this referral will be included among the limited number of assessments available to First Nations schools in BC.
2.
Consent for Assessment - If your child is selected for assessment, the school would also like your consent for the assessment itself. Dr. Leonard Stanley, along with his psychology team, will coordinate the assessment with the school and FNESC.
If your child is not selected by FNESC for assessment during this upcoming school year, the consent must be renewed for any future referral in the future. Authorization and participation in the psychological assessment are voluntary.
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Right to Withdraw
The parent/guardian/independent student will be notified in advance when the assessment is to take place and they may revoke this consent at any time by notifying the principal of the child’s school.
Confidentiality
Information will be strictly confidential. Results will be used in the school only by those responsible for developing a support program for your child. The psychologist will keep a confidential copy of your child’s results and a digital copy will be housed in the FNESC office.
I hereby consent to have my child, ______________________________________,
Please check boxes to indicate your consent for the following:
REFERRED FOR POSSIBLE ASSESSMENT - I understand that the FNESC/FNSA
special education team will examine information to determine if my child should be assessed
during the upcoming school year, but that they may not select my child for assessment this
school year.
CONSENT FOR ASSESSMENT - If my child is selected, I hereby consent to have my
child participate in a Psycho-Educational Assessment by a FNESC approved psychologist as
described above.
__________________________ ___________ ______________________________
Name of Principal or Designate Date
(mm/dd/year)
__________________________ ___________
Name of Parent/Guardian/ Date
Independent Student (mm/dd/year)
Signature of Principal or Designate
______________________________
Signature of Parent/Guardian/
Independent Student
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School Based Referral Action Steps
1. Teacher refers the student to the School Team.
2. School selects a school based contact person.
3. If SET-BC services are needed, the school completes the First Nations School Screening
School Based Responsibilities
1. School Team completes the Screening
Checklist. School based contact person submits the Screening Checklist to the
FNESC/FNSA office.
2. If selected for technology solution, the school
- eligible individual students have very complex needs requiring specialized technology to access the curriculum.
4. Submit the First Nations School Screening
Checklist to the First Nations Education Steering
Committee (FNESC)/First Nations Schools
Association (FNSA) office. student team for consultation and training with the SET BC consultant.
3. The school provides peripheral devices (eg printer, scanner) and consumable items as required.
4. Security for the SET BC loaned technology.
FNESC/FNSA and SET-BC Agreement
SET-BC Mandate
SET-BC is a Provincial Resource Program designed to assist BC School Districts in meeting the technology needs of students with physical disabilities, visual impairments and autism. SETBC’s mandate is:
1. to loan assistive technologies (reading, writing, and communication tools) where those are required to ensure students’ access to educational programs, and
2. to assist School Boards in providing the necessary training for students and educators in the use of these technologies.
In 2007, the First Nations School Association membership agreed to use a portion of the BC
Special Education Program (SEP) funding to enter into an agreement with SET-BC for the provision of services to students in First Nations schools with special needs that fit within the
SET-BC mandate.
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Student Name:
Submitted By:
2015/05/29
YY / MM / DD
Date Submitted:
for SET-BC Service
Please Return form to:
Tel: 604-925-6087
First Nations Education Steering
Committee (FNESC)
Attention: Barb O’Neill
Fax: 604-925-6097
Due Date:
Suite 113, 100 Park
Royal South, West
Vancouver BC T2A1A7
Email: barbo@fnesc.ca
Student is currently using SET-BC
Assistive Technology Yes No
Student is currently using Assistive
Technology Yes No
Surname
SET-BC / District Partner use only Service Points
City:
1.2 Student Status Information:
Given name(s)
Home Address (Complete Mailing Address)
Postal Code
Student is reported as: Deaf/Blind (DB)
physically handicapped /chronic health (PH)
dependent handicapped (DH)
autistic (AUT)
moderate to profound (MP)
visually impaired (VI)
Grade:
Birth Date (yy/mm/dd)
Gender
M F
Type of Impairment (Check those that apply)
motor vision communication
cognitive
Disability Diagnosis:
1.3 School Information:
Key School Contact Person:
Name of School:
School Mailing Address:
Classroom Teacher:
Classroom Teacher Email:
Position: Email:
School Principal:
School Principal Email :
Telephone:
School Telephone:
City:
Teaching Assistant:
Teaching Assistant Email:
Facsimile:
School Facsimile:
Postal Code:
1.4 Parent Guardian Information:
Parent / Guardian Name:
Complete Mailing Address :
Email:
Postal Code:
Telephone (Home)
Telephone (Work)
Foster Parent Family Name (if applicable): Email: Telephone (Home)
Complete Mailing Address (if applicable): Postal Code: Telephone (Work)
1.5. Referrals and Services Received:
Special Education Services Received: (please check all that apply)
Speech / Language Services
Services for the Visually Impaired
Physical / Occupational Therapy
Services for the Hearing Impaired
Has this student been referred to and/or received services from other programs? Please name program and specify year.
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2. 1. Cognitive / Academic Level:
Cognitive Level: (based on psycho-educational assessment)
above average average mild delay moderate delay severe / profound delay
Achievement Level: not yet meeting reading reading comprehension
written language minimally meets math / numeracy
Pre-academic skills:
(describe if applicable) Recognizes objects choice making ability:
photos line drawings visual matching skills:
2.2. Motor Skills fully meets exceeds
No Concerns
Mobility: walks independently walker
crutches/cane
other (eg. crawls.)
manual wheelchair
self propels
non propellor
Hand Use
(dominance & function) :
right hand
power wheelchair
age appropriate
left hand
impaired/delayed
both
not functional
Typing Speed WPM
Comment::
Please rate student use with the following scale: B = beginner SP = some proficiency P = proficient NA = not applicable
B SP P NA B SP P NA B SP P NA regular keyboard regular mouse joystick trackball regular pencil adapted pencil grip alternate keyboard
(specify type) head pointer hand switch head switch switches alternate site
Physical needs:
scribing extended time reduced workload
2.3. Vision
Visual
Impairment:
low vision
totally blind
visual field restrictions
cortical visual impairment
colour vision deficit
progressive writing samples attached
No Concerns
Acuity right eye left eye both eyes
Reading
Medium:
Braille
large print (lp)
lp with speech support
auditory only large print (preferred fon t size)
Braille: uncontracted contracted
Student
Ability: typing speed Optical Aids Used preferred magnification low vision clinic (include report)
2.4. Communication
Speech/Language: speaking
non-speaking: communicates by ( explain briefly below )
articulation difficulties
sign language
gesturing/pointing
communication boards/books
Picture Exchange Communication
System
simple speech output device (Big Mac)
language difficulties
dedicated voice output communication device
other ( specify )
What is the student’s primary mode of communication?
No Concerns
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2.5. Social / Behavioural
Please Describe:
peer interaction
time on task / attention span
work productivity
impulsivity
safety issues
no concerns
2.6. Access to Curriculum (student snapshot)
What barriers prevent this student from meeting reasonable educational goals? evaluation criteria:
Please indicate your School Team’s readiness to implement technology:
Technical Skills/Support o School Team’s technical skills o Access to tech support within the school
beginning
limited
intermediate
adequate
School Support
No Concerns
What non-technical and / or technical strategies have been investigated or put in place to overcome the barrier(s)?
Please indicate and comment on the student’s willingness to use technology and on his / her technology preference.
List 1 primary goal. Two additional goals may be recorded.
The student’s educational program is
modified adapted other (explain)
Technology will be used: in class, in resource room, in multiple locations.
Estimate frequency of technology use a in the student’s program
occasionally (1-2 times per week)
on a daily basis (up to one hour per day)
frequently (3-5 times per week)
almost continually (3-5 hours per day)
Please list the primary educational goal that will be supported through the use of technology. Include current level of functioning (baseline statement) and how progress will be measured specific to the affect of A.T.: (attach copy of IEP)
Goal 1: current level of functioning: evaluation criteria:
Goal 2: current level of functioning: evaluation criteria:
Goal 3: current level of functioning:
advanced
occasionally
Availability for meetings
Release time for training
Purchase of peripherals (printer, scanner)
Purchase of consumables (printer ink, etc.)
Purchase of educational\productivity software
School based transition plans
limited
limited
limited
limited
limited
limited
adequate
adequate
adequate
adequate
adequate
adequate
easily met
easily met
easily met
easily met
easily met
thorough
Will the student be transitioned to a new team or new school next year? yes no
Please comment
(not supplied by
SET-BC)
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4.1 School Team:
Please list school personnel involved with this student
Job Role
Parent/Guardian
Classroom Teacher
Resource Teacher
Speech/Language Pathologist
Augmentative Communication Consultant
Vision Teacher
Occupational Therapist
Physiotherapist
Teaching Assistant
Counselor
Name Aware of this referral
yes no
yes no
yes no
yes no
yes no
yes no
yes no
yes no
yes no
yes no
yes no Other
What computer platform is currently in the school? Macintosh Windows
Are there other SET-BC computers in the school? Yes No
How is the student currently accessing computers in the school? (include location and frequency of access)
What type of technology is currently in place for the student? (include hardware and software)
What type of technology has been recommended / are you considering requesting from SET-BC ?
Screen magnification
Portable word processor
Computer
Screen magnification with speech
CCTV
Talking word processing software
Word prediction
Print to Braille software and Braille printer
Screen reader
Picture processor
Integrated scan/read/write software
Refreshable Braille device
Alternate access
Augmentative and alternative communication software
Augmentative and alternative communication device
Other
Please list attached documents:
NOTES:
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Successful selection and implementation of Assistive Technology may include:
 effective consultation including student input, to ensure a good match of technology features to student need
 clear educational goals and a clear idea of how technology will support those goals
 adequate time for School Team planning, training and follow-up training
 the School Team sharing responsibility for solving problems, creating overlays/templates, monitoring use, etc.
 integration throughout the daily schedule
 adequate practice time for the student
 adequate funding for purchase of necessary peripherals (printers, scanners) or consumable items (printer ink, batteries, etc.)
 coordinated maintenance and support
SET-BC provides: consultation services to match technology to student need loan of assistive technology to First Nation schools for the use of eligible students
(software and/or hardware) school team training, follow-up training and re-training implementation resources technical support to maintain and repair SET-BC equipment
School Team undertakes to provide: release time for consultation, planning meetings, follow-up training and retraining peripheral devices (printers, scanners) and consumables as needed access to additional educational software required, e.g. MS Word safekeeping of the SET-BC loaned technology
School Team Commitment:
I have read the suggested guidelines for successful implementation of assistive technology and I understand the School Team’s responsibilities. Should my student be allocated SET-BC service,
I am committed to providing time and the resources listed above to successfully implement the assistive technology.
School Principal Signature Date
School-based Contact Signature Date
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Student Name: ___________________________________
Date of Birth: ____________________________________
I understand that an application is being made to the First Nations Education Steering
Committee (FNESC) and to the First Nations Schools Association (FNSA) for SET-BC services for my child. As part of that application, I understand that the School,
________________________, must provide information about my child to the FNESC and
FNSA for evaluation. That information may i nclude information about my child’s special needs, medical and educational history, Individual Intervention Plan, testing and assessment results and similar information. I understand that information will be used by FNESC and the FNSA for the purposes of making a decision about providing additional funding for services for my child. I understand why I have been asked to release information and am aware of the risks or benefits of consenting or refusing to consent to release this information. I understand that all information will be treated as confidential by FNESC and FNSA, but that it will be disclosed within FNESC and FNSA to those individuals who are considering the funding application. I also understand that I may revoke this consent at any time by submitting a written revocation document to the
FNESC. I understand that if I do not consent to the release of this information that my child may not receive the support services that would be funded by this application.
□ Yes □ No I authorize release of school records to FNESC and the FNSA, including the records described above, concerning my child for the purpose of my child’s school applying for
Special Education SET-BC Services/resources for the above. The records should be directed to:
Special Education Program,
First Nation Education Steering Committee &
First Nations Schools Association
#113 – 100 Park Royal South
West Vancouver, BC, V7T 1A2
Tel (604) 925-6087
Fax (604) 925-6097
Signature of Parent/Guardian: ________________________________________
Name of Parent/Guardian (please print): ________________________________
Date: ____________________________________
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