ESC Region 11 Assistive Technology/Equipment Request for Students with Visual Impairments

Assistive Technology / Equipment Request for Students with Visual Impairments

This form must be completely filled out, signed by the special education director and contain all attachments before the request can be considered.
Person Making Request
Name*

First NameLast Name
Title *
Email *
example@example.com
Phone Number*
Name of LEA/ISD/SSA*
Campus*
Student Name

First InitialLast Name
If this equipment is not for a specific student, explain reason for request
Documentation and Needs

Please upload a copy of one or more of the documents below that addresses the need for this equipment request.
Functional Vision Assessment Date

MonthDayYear
Learning Media Assessment Date

MonthDayYear
Technology Assessment Date

MonthDayYear
Low Vision Evaluation Date

MonthDayYear
Attach documentation of need.

All documents will be encrypted in JotForm, however if you wish to remove identifying information please do so.
Cancelof
Equipment currently used by this student:*
Requested equipment, manufacturer's name, address and phone number:*
Cost
Shipping Cost
Attach a copy of the quote with the item number and specific ordering information:

Cancelof
Is technical assistance required for installation?*

yesnounsure
Is technical assistance needed for ongoing use?*

yesnounsure
Plan for training the student is:*
How will the use of this device enable the student to participate in the general curriculum and/or school subjects and/or activities:*
Agreements
Equipment is purchased by ESC, Region 11 Supplemental Funds for Student with Visual Impairments, provided funding is available. The equipment is available on long-term loan; however, the District/Co-op is responsible for all repairs and keeping the equipment in good working condition at all times.

If the student no longer needs the equipment, please notify the Regional Visual Impairment Specialist at ESC Region 11.

Educator of Students with Visual Impairments Signature:
I acknowledge my understanding of the long-term loan requirements, and I verify that all the information contained in this request is current to the best of my knowledge.
VI Educator Signature Date
Administrator/Special Education Director*

First NameLast Name
Administrator/Special Education Director Email*
example@example.com
When this form is submitted it will be emailed to your administrator for their signature. The technology request cannot be approved by ESC Region 11 until all signatures and supporting documentation are received.
Add a note to your administrator: administrator note

Administrator Signature (expand to sign)
I acknowledge my understanding of the long-term loan requirements, and I verify that all the information contained in this request is current to the best of my knowledge.
Administrator Full Name Administrator Title Date
Signature:

Clear

Submit
ESC Region 11 cannot access saved forms. Once this form is completed and ready for your administrator to sign, please submit using the green submit button. The form will be routed to your administrator for signature and you will be notified by email once that signature has been completed.

If you need assistance please contact:
Alecia Davidson adavidson@esc11.net
Technology Requests will be processed on the first Friday of each month.
Should be Empty:

Assistive Technology / Equipment Request for Students with Visual Impairments

Documentation and Needs

Agreements