Deaf and Hard of Hearing Request for
Assistive Technology
Incomplete requests or those that have not been reviewed by the
school district liaison will be returned
The Assistive Technology (AT) Process
 Team meets and identifies areas of student need and considers possible assistive technology devices or services
 AT Consideration checklists (available at http://wiu.k12.pa.us ) are used to review past and potential interventions
o Past or current tools and interventions are noted and described in terms of their outcomes
o Potential AT tools and interventions are identified for trial or implementation – the Assistive Technology Action Plan is used to document
targeted tools and strategies, individual responsibilities, and AT trial results
 If the team determines that the further assistance of a WIU Assistive Technology Coordinator is required, a Request for Assistive Technology
Consultation packet is completed by the team and forwarded to the school district’s special education liaison for review
o AT Coordinator reviews information from the liaison, communicates with various team members, and makes site visits (as appropriate)
o Recommendations are shared with the team using the Assistive Technology Action Plan
 Team members meet to review the recommendations, identify available resources, clarify needed supports, outline action steps, and agree to
responsibilities for action steps
 Team members meet to discuss the outcomes of trials and update the IEP/IFSP, if warranted
Estimated Timelines when a Request for Assistive Technology Consultation is Used
District
 Request for Support completed by
team and forwarded to liaison
 Request reviewed by the special
education liaison/LEA
 Signed Request for AT
Consultation and supporting
documentation are sent to the
WIU Assistive Tech Coordinator
10 days
Intermediate Unit
District
 Request received and reviewed  Recommendations are made  Assistive Technology
 Trials and training
and forwarded to the team
Action Plan is reviewed
conducted, as needed
 Consultation occurs via
via
the
Assistive
Technology
and
completed
by
district
phone, email, or onsite visit
 District team meets to
Action Plan
team members
review outcomes of trial or
discuss recommendations
 IEP developed or revised,
as needed
30 days
10 days
10 days
Please mail this completed form and supporting documentation to:
Candice Hite –AT Coordinator
Natalie Panaia-Audiologist
Westmoreland Intermediate Unit #7
102 Equity Drive
Greensburg, PA 15601-7190
Westmoreland Intermediate Unit #7
Audiology AT Request for Support
April 2014
This packet must be completed in print/type by the Building Team Contact and reviewed by the District Liaison/LEA upon packet completion.
Student:
Date of Birth (Age):
K-Age (Kindergarten/EI only):
District/School/Grade/Support Type:
District of Residence (if different):
Building Team Contact Name:
Contact’s Email:
Contact’s Phone:
Contact’s Fax:
Student & Team Availability:
Please indicate the days and time periods that the student and team members are available for onsite visits (Check all that apply)
Monday
AM
PM
Special scheduling concerns:
Tuesday
AM
PM
Wednesday
AM
PM
Thursday
AM
PM
Friday
AM
PM
Reviewed by (REQUIRED):
Incomplete requests or those that have not been reviewed by the school district liaison will be returned.
Signed, completed requests will only be processed by the AT Coordinator after all documentation has been received.
Liaison/LEA Signature
For electronic submission only:
Westmoreland Intermediate Unit #7
Date of Review
Checking this box in lieu of a signature indicates that this request has been approved by the designated school district liaison.
The reviewer’s name and review date must be indicated on the appropriate lines above.
Audiology AT Request for Support
April 2014
Areas of Concern (Check all that apply):
Expressive Communication
Receptive Communication
Computer Access
Mathematics
Mobility
Organization
Reading
Seating & Positioning
X Sensory Needs – Hearing
Sensory Needs – Vision
Writing – Composition
Writing – Fine Motor
Please print or type:
Based on the collaborative review, what educational concerns does the team hope to have addressed by this assistive technology consultation? What are
the desired outcomes?
What supports are currently available to the student and team in terms of assistive technology? Describe pertinent strategies, devices, and personnel.
Which strategies from the Assistive Technology Considerations checklists have been considered or attempted?
Additional information or comments:
Westmoreland Intermediate Unit #7
Audiology AT Request for Support
April 2014
Assistive Technology Considerations for Sensory Needs
(Hearing)
Student Name:
Observed Needs:
Y
N
Grade & Age:
Hearing
AT Intervention
Use classroom infrared/sound field system
Use personal to table FM system
Use personal FM system
Use hearing aids
Use cochlear implants
***Surgically implanted MEDICAL DEVICE
Use BAHA (Bone anchored hearing aid)
*** Surgically implanted MEDICAL DEVICE
Independence with
Technology
Frequency/Duration of Use
Outcomes
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
Complete
With Initial Setup
Assisted
***A MEDICAL DEVICE that is surgically implanted or the replacement of such a device is not classified as an assistive technology device
as per IDEA 2004 Sec. 300.5.
Adapted from Technology and Media Division of the Council for Exceptional Children & Wisconsin Assistive Technology Initiative (n.d.) Assistive Technology Quick Wheel, available at http://www.ideapractices.org/ or http://www.cec.sped.org/ and from
Beukelman, D. R. & Mirenda, P. (1998). Augmentative and alternative communication: Management of severe communication disorders in children and adults. Baltimore: Paul H. Brookes.
Westmoreland Intermediate Unit #7
Audiology AT Request for Support
April 2014
Assistive Technology Roles and Responsibilities Matrix
Team Role
Student
Name
Email
Phone
Natalie Panaia
npanaia@wiu.k12.pa.us
724-836-2460 x2322
Candice Hite
chite@wiu.k12.pa.us
724-836-2460 x2123
Parent
Special Educator
General Educator
Paraeducator
Audiologist
Speech Language Therapist
Occupational Therapist
Physical Therapist
AT Coordinator
Building Principal
Psychologist
Building Tech Staff
District Tech Staff
LEA
Assistive Technology Product
Westmoreland Intermediate Unit #7
Website
Vendor Address & Phone
Audiology AT Request for Support
Notes
April 2014
Hearing Therreapist
District Tech Staff
Building Tech Staff
Psychologist
Administrator
AT Coordinator
Physical Therapist
Occupational Therapist
Audiologist
Paraeducator
General Educator
Special Educator
Parent
List all actions that must be done for this student. For each item,
agree on a team member who is (A) Assigned for responsibility and
one who is (B) Back-up. Team members should speak for
themselves rather than be assigned to items. No one person should
serve as Assigned for all items. Each team member should assume
Assigned or Back-up responsibility for at least one item.
Student
Responsibilities
(A) Assigned (B) Back-up
Speech Language Therapist
Assistive Technology Roles and Responsibilities Matrix
A
Selecting appropriate equipment
A
Ordering Equipment
Receiving and Checking in Equipment
A
B
Training student and staff on care and use of equipment
A
B
Troubleshooting Equipment
A
B
Repairs/Returns
A
B
Charging unit nightly
A
B
Preparing unit daily
A
B
Adapted by Kelly Fonner, http://www.kellyfonner.com/, kfonner@earthlink.net, Modified by Allegheny Intermediate Unit #3
Westmoreland Intermediate Unit #7
Audiology AT Request for Support
April 2014
Westmoreland Intermediate Unit #7
Audiology AT Request for Support
April 2014