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 Consultation Request Form
Request Submitted by: *

First
Last
Date *

MM		/
DD		/
YYYY

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 Email

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

###		-
###		-
####
Extension
Does your school district have
an assistive technology team?
 Yes 
 No 
If yes, please provide contact
information for an AT team
member
Phone Number

###		-
###		-
####

PLEASE PROVIDE THE FOLLOWING INFORMATION ABOUT THE STUDENT

Brief description of the
student's abilities:
Student's daily schedule:
(arrival/departure time)
Current educational placement
(grade level, classroom),
including related services:
Describe the assistive
technology currently being
used:
Describe assistive technology
that has been previously tried.
Include AT NAME;
LENGTH OF TRIAL;
RESULT OF TRIAL:

Check the primary area(s) of concern for the student related to assistive technology and list
what task(s) you want the student to do, that s/he is unable to do, at a level that reflects
his/her skills and abilities?

Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.
Area of Concern
Use the drop down arrow to choose the area(s) of concern
for the student related to assistive technology.
Tasks:
Describe tasks related to this area of concern
that the student has difficulty completing.

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