Oklahoma Assistive Technology Center University of Oklahoma Health Sciences Center Department of Rehabilitation Sciences College of Allied Health 1600 N. Phillips Oklahoma City, OK 73104 PH: 405-271-3625 TDD:405-271-1705 FAX: 405-271-1707 TOLL FREE: 800-700-6282 Assistive Technology Program for Oklahoma Public Schools Assistive Technology Evaluation Request Form
Request Submitted by: *
Prefix
First *
Last *
Suffix
Date *	MM / DD / YYYY
The following questions are intended to provide staff at the Oklahoma Assistive Technology Center with specific information to consider about the student and will assist us in preparing for the evaluation of the student's need for assistive technology.
The Cost for an assistive technology evaluation is $750.00 and a purchase order or requisition is required to be submitted along with this request.
STUDENT INFORMATION
Student Name
Prefix
First
Last
Suffix
Student Date of Birth	MM / DD / YYYY
Student Age
Student Grade
Disability
Parent(s) Names
Parent Home Phone	### - ### - ####
Parent Work Phone	### - ### - ####
Extension
Parent Cell Phone	### - ### - ####
Parent Email
Parent Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Classroom Setting Please check all that apply	Regular Education Class   Resource Room   Self-Contained Classroom   Home   Other
SCHOOL DISTRICT INFORMATION
School District Name
School Campus Name
Campus Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
School Primary Contact
Prefix
First
Last
Suffix
Primary Contact Phone Number	### - ### - ####
Extension
Primary Contact Email *
Primary Contact's Role/Relationship to Student
Special Education Director
Phone Number	### - ### - ####
Purchase Order or Requisition Number (Please attach copy)
Billing Address
Street Address
Address Line 2
City
State / Province / Region
Postal / Zip Code
Country
Individual Responsible for Billing
Phone Number	### - ### - ####
Please list the IEP Team members who will participate in the evaluation process. These are generally individuals who work directly with the students and can provide information about the student's abilities and needs in the educational environment.
Name; Position; Phone Number
Does your school district have an assistive technology team?	Yes   No
If yes, please provide contact information for an AT team member
Phone Number	### - ### - ####
Describe assistive technology currently being used in the following curriculum/access areas
None
Computer Access
Motor Aspects of Writing
Composing Written Materials
Communication
Reading
Learning & Studying
Math
Recreation & Leisure (PE)
Seating & Positioning
Mobility
Vision
Hearing
Other
Please describe any other assistive technology that has been tried previously, the length of the trial, and the outcome (how did it work, or why it didn't work).
Assistive Technology; Length of Trial; Outcome
By submitting this request for an Assistive Technology evaluation, you verify that all involved parties (school and family) are aware of and consent to this request.
Additionally, you hereby give consent for OATC staff to conduct an Assistive Technology evaluation for the student indicated in this request.

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