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: *

First
Last
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

First
Last
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

First
Last
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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