D. Complete the Authorization for Use and/or Disclosure of Information form (D/M 63) and obtain the parent/guardian signature. Specify the receiving agency’s name, if known. If not, leave the field blank. Referral Procedures Forward the following completed documents to the attention of the Program Manager for Resolution Support Services at the SELPA. • D/M 127 Assistive Technology Assessment Referral form • D/M 66 Assessment Plan form • D/M 63 Authorization for Use and/or Disclosure of Information form • IEP or IEP Addendum dated within one year of the referral for an Assistive Technology Assessment • Psycho-educational evaluation dated within three years of the referral for an Assistive Technology Assessment • Any additional supporting information Timeline for Assessment Within five business days of receipt of the completed referral packet, the Program Manager for Resolution Support Services at the SELPA will assign the assessment to an independent assessor who will coordinate the assessment through the contact person named on the referral form (D/M 127). Timeline for Services Upon completion of the assessment, a report will be sent to the Director of Special Education by either the agency that conducted the assessment or the Program Manager for Resolution Support Services at the SELPA with a request to schedule an IEP meeting. The Director of Special Education will reconvene the IEP team to review the report findings and recommendations of the assessment and determine whether or not AT services are warranted. If the IEP team agrees that services are not needed, it will be documented in the IEP notes. How to request Low Incidence Funding for Assistive Technology Recommended by Assessment (1) For students with a documented low incidence disability for whom assistive technology, equipment is recommended after an assessment, use the following procedure for equipment requests other than mobile devices/applications:
Chapter 22 – Supports and Services, Charter SELPA As of 10/17/2019 D/M Charter SELPA Steering Committee Approval
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