1. Convene an Individualized Education Program (IEP) meeting to document the team’s decision to refer the student for an Assistive Technology (AT) Assessment. 2. Complete the Assistive Technology Assessment Referral form (D/M 127) and obtain the signatures of the person making the referral and the director of special education. 3. Complete the Assessment Plan form (D/M 66) and obtain the parent/guardian signature. 4. The person making the referral should check the box that corresponds to the type of assessment(s) requested. Write Assistive Technology Assessment on the line for “other.” 5. The parent/guardian should initial each applicable statement listed under the Parental Authorization section of form D/M 66. 6. 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 determine whether to conduct the assessment using a multi-disciplinary team approach or assign the assessment to an independent assessor who will coordinate the assessment through the contact person named on the referral form (D/M 127). All assessments must be completed within 60) days.
Chapter 5 – Supports and Services, Desert/Mountain SELPA As of 10/18/19 D/M SELPA Steering Committee Approval
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