MURRAY SCHOOL DISTRICT
ASSISTIVE TECHNOLOGY TEAM
5175 S. Parkside Drive  Murray, UTAH 84107
PHONE: (801) 264-7434
FAX: (801) 264-7453
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Initial Referral Form for Assistive Technology
Complete both pages of this form.
Include a copy of the IEP or 504 so we can base services off the student’s goals.
Please have your principal sign this form.
Submit form to the Assistive Technology Team at Parkside Elementary c/o Joelle Rasmussen.
Student: __________________________
DOB: ___/___/___
Date: ___________________
Parent/Guardian: ________________________________ _
Phones: _________________
Address: __________________________ City: _____________
Zip: ____________________
School: ___________________________ Grade: _______
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Regular Education Teacher:_____________ _____________________________________
Special Education Teacher/Case Manager: _________________________________________
Current Services: IEP  504
Referral Person: ______________________________________ Phone: __________________
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Reason for Referral:
Please describe the difficulties your student is having participating in his/her educational program:
Special Education Eligibility:
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Orthopedic Impairment
Hearing Impairment
Deafness
Deaf/Blindness
Intellectual Disability
Vision Impairment
Multiple Disabilities
Other Health Impairment
Speech-Language Impairment
Traumatic Brain Injury
Specific Learning Disabilities
Emotional Disturbance
Autism
Behavior Disordered
Developmental Delay (ages 3 through 7)
Related Service:
Type of Service:
Hours Per Week
Name of provider
Medical Diagnosis/Information:
Vision:
Date of most recent formal test/screening: _________________________________________________
Based on formal and informal measures, student exhibits:
no visual impairment
suspected visual impairment
documented visual impairment
Additional Information: _________________________________________________________________
Hearing:
Date of most recent formal testing/screening: _______________________________________________
Based on formal and informal measures, student exhibits:
no hearing loss
suspected hearing loss
mild hearing loss (left ear; right ear; both)
Moderate hearing loss (left ear; right ear; both)
Severe hearing loss (left ear; right ear; both)
Deaf
Additional information:__________________________________________________________________
Areas of Concern:
Student is experiencing difficulty accessing education in the following areas:
Communication
Handwriting (legibility)
Written Expression
Spelling
Reading
Math
Other academic subjects. Describe: ____________________________________________________
Organization (describe): _____________________________________________________________
Participating in inclusive setting (describe) : _____________________________________________
Accessing Print Materials: ___________________________________________________________
Access to Educational Materials due to physical handicap (describe)
Toys Computer Books Other (describe):
Principal’s Signature: ______________________________________ Date: ____________
Date Received by AT Team: