SHAKOPEE PUBLIC SCHOOL
SHAKOPEE, MN
Request for Assistive Technology Trial
Please complete this form to request an Assistive Technology (AT) Trail. The district AT Consultant or DHH or
Vision staff will acquire the type of technology to be used for the trial.
Date:
IEP Manager:
Student Name:
ID#:
School:
DOB:
Primary Disability:
Grade:
Please attach documentation that shows the need for Assistive technology.
Present levels of performance
IEP Goal(s)
IEP Accommodations/Modifications
Other documentation
AT requested for trial (Describe type of device. A specific named device may not be guaranteed for use in trial).:
Person(s) responsible for collecting data:
Type of data collecting:
speed
accuracy
spontaneity
duration
latency
Criteria for success of trial:
Time needed for trial:
Trial Start Date:
Trial End Date:
Post Trial team meeting date:
The result of this trial:
The trial showed the need for AT to reach IEP goals. (Attach documentation of results.)
The trial showed the need to have another AT trial.
The trial showed that AT was not useful in reaching current IEP goals.
If you have questions, please contact the district AT consultant, Stephanie Betley, at
sbetley@shakopee.k12.mn.us (952-496-5024) or DHH Teacher or VI Teacher
Attach this form to the student’s current IEP in the student’s due process folder.
Revised
04/09
other