Procedure – Category 5000 (Students) AR 5005.4 – SELPA Referral Procedures
Store, Google Play Store, Galaxy Store, etc.), rather than traditional hardware operating system built into a desktop or laptop computing system. • Complete SELPA Low Incidence Pre-Approval Request for Mobile Computing Device form (DM 86B). Director of special education must sign form DM 86B before the packet is submitted. The SELPA or the LEA will be responsible for purchasing the mobile computing device and educational device applications that meet criteria as educationally appropriate to the child’s functional level. The SELPA will assign the low incidence equipment/ID number, download the approved device applications, and coordinate the delivery and release of the equipment to the LEA/student. When the LEA purchases the equipment, this will be indicated on the LIE pre-approval request form. NOTE: Entertainment/game applications will not be permitted.
2.3
Assessment for Non-Low Incidence Equipment A. Pre-referral LEA Responsibility:
1. Convene an IEP meeting to document the team’s decision to refer the student for an AT assessment. 2. Complete the Assistive Technology Assessment Referral form (DM 127) and obtain the signatures of the person making the referral and the director of special education. 3. Complete the Assessment Plan form (DM 66) and obtain the parent/guardian signature. 4. Complete the Authorization for Use and/or Disclosure of Information form (DM 63) and obtain the parent/guardian signature. Specify the receiving agency’s name, if known. If not, leave the field blank.
B. Referral Procedures Forward the following completed documents to the attention of the Program Manager for Resolution Support Services at the SELPA: • DM 127 – Assistive Technology Assessment Referral
AR 5005.4 – SELPA Referral Procedures Desert Mountain Charter Special Education Local Plan Area (DMCS) (rev. 8/9/22)
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