AIU Assistive Technology (AT)
Consultation Request
TEAM USE
Student Name:
School District:
School Building:
AIU USE
Date completed documents received:
Training and Consultation (TaC) Coordinator-AT:
Consultation will be scheduled ONLY after AT REQUEST FORM, ER/RR, and IEP are received via email from the Special Education Administrator.
Incomplete or NON-Microsoft Word format requests will be returned to the administrator.
Submit Request to: dori.anderson@aiu3.net
Revised July 2015
The following changes are in effect as of August 1, 2015
AIU Assistive Technology Request Process
1. The student’s team should determine the need for an AT consultation. The AT Consultation Request should be completed through
a collaborative effort by the team, including the parents. Documents containing the AIU Assistive Technology Considerations
Checklists and AIU Assistive Technology FAQs are provided as resources in completing the request. If you have not received the
resources and would like to use them, please see http://assistivetechaiu.wikispaces.com
2. The student’s team should forward the completed AT Consultation Request to the Special Education Administrator for review,
approval, and submission via email.
3. A Microsoft (MS) Word version of the AT Consultation Request document must be submitted by the Special Education
Administrator via email along with digital copies of the student’s current Evaluation/Reevaluation (ER/RR) and current
Individualized Education Plan (IEP) or 504 Plan.
 Team completes information on cover page and the AT Consultation Request.
 Any additional documentation that the team and/or administrator feels pertinent for the AT consultation may also be included as
email attachments.
4. All AT request documentation and questions regarding an AT request should be emailed to:
Dori Anderson, Training and Consultation Coordinator, Assistive Technology (TaC–AT) dori.anderson@aiu3.net
5. PLEASE NOTE: If the student’s primary diagnosis is Blind/Visual Impairment, contact Michael Horvat, AIU Vision Assistive Technology
Specialist michael.horvat@aiu3.net
Revised July 2015
2
AIU Assistive Technology Support Options
Option A: Consultation
Option B: Training
Option C: Use of AIU AT Forms
Team, including parents, requests AT
consultation to identify tools and/or strategies
for individual students with IEPs or 504
agreements
Team does not request an AT consultation for
an individual student
Team does not require an AT consultation
or services
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No consultation or training is provided
by the TaC-AT
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Team completes AT Consultation Request
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Onsite consultation conducted: Observation
and/or direct work with the student
The team identifies the specific tool for training
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The team may complete the SETT FrameworkPart II to document use of the tool for specific
tasks across environments
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TaC-AT facilitates the development of the SETT
Framework-Part II (AT Action Plan) with the
student’s team (minimum of two as determined
by the team)
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The team may use AIU AT forms to document
information in preparation for IEP planning or
program development
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The team may opt to use forms for recordkeeping and data collection purposes
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To request building or district-wide
training of a particular AT tool
Contact:
dori.anderson@aiu3.net
The team does not need
to send forms to the AIU
It is recommended that a copy
be retained in the student file
The primary contact disseminates AT Action
Plan to team members, including parents
Revised July 2015
3
AT Consultation Request 1 of 4
ALL four (4) pages MUST be completed and should be completed through a collaborative effort by the student’s team, including the parents
Student Information
Name:
Date of Birth/Age:
District/School:
District of Residence:
Grade/Educational Placement:
Current IEP Date:
Current ER/RR Date:
Student/Team Availability
Consider times during classes, activities, & therapy sessions in which assistive technology may be needed as well as days and times that the student and team
members especially related service providers are available.
Monday
Tuesday
Wednesday
AM
AM
AM
PM
PM
PM
Thursday
Friday
AM
AM
PM
PM
Arrival Time:
Dismissal Time:
Student Lunch:
Recess:
Therapy Sessions (day/time):
OT:
Vision:
PT:
Hearing:
Speech-Language:
Revised August 2015
4
AT Consultation Request 2 of 4
Team Members
Role
Primary Contact
Student
Parent/Guardian
Special Ed/Agency Admin
Building Principal
General Education Teacher
Special Education Teacher
Speech-Language
IT Building Contact
OT
COTA
PT
Teacher of VI/Blind
Teacher of Deaf/HH
Program Supervisor
Name
Email
Phone
Team members to attend AT Action Plan meeting following AT Consultation: [Minimum of 2]
Name:
Name:
Name:
Name:
Name:
Name:
REQUIRED Special Education Administrator APPROVAL
Name:
Revised August 2015
Date Approved:
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AT Consultation Request 3 of 4
The SETT Framework – Part I: Team Consideration of Student Need for Assistive Technology
SETT
WHAT WE KNOW
ABOUT OUR STUDENT
WHAT WE NEED TO KNOW
ABOUT OUR STUDENT
STUDENT
What does the student need to do but
independent completion is difficult? e.g. special
needs& current abilities (related to areas to be
addressed), expectations & concerns, student
interests & preferences
ENVIRONMENTS
What is the impact on student performance across
different environments? e.g. instructional &
physical arrangements, supports of staff & student,
materials & equipment, access issues, attitudes &
expectations of staff and family
Revised August 2015
6
AT Consultation Request 4 of 4
The SETT Framework – Part I: Team Consideration of Student Need for Assistive Technology
SETT
WHAT WE KNOW
ABOUT OUR STUDENT
WHAT WE NEED TO KNOW
ABOUT OUR STUDENT
TASKS
What SPECIFIC tasks occur in the student’s natural
environment to enable progress toward mastery
of goals? What SPECIFIC tasks are required for
active involvement? e.g. communication,
instruction, productivity, and participation
TOOLS
By SPECIFIC name list all “NO-LOW-HIGH” tech
options that have been trialed.
Explain how they have or have not yielded positive
outcomes.
NOTE: Refer to the AT Considerations Checklists
to complete this section
Revised August 2015
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