Assistive Technology Proposal for Device Purchase
Student’s Name:Date of Request:
School:Referring/Contact Person:
Certification:
Team Members:
Work Phone:Email address:
Requesting Device:Cost:
Identify the needs/objectives to be accomplished for this student through the use of assistive technology. Include all environments where the device is needed.
What features must a device have to meet the student’s identifed goals?
What is the rationale for your recommended device and how does it match with features required?
What other devices were considered/used and rejected and why? Please list lite tech and high tech.
Has the recommended device been used for a trial period with this student?
YesNo
If yes, briefly describe the results.
Summary of results:
If no, please explain why the device was not trialed.
Who is the primary “contact” person that will be responsible for all of the following?
- Picking up and signing of the device at the Lending Library, Contacting appropriate person(s) for repair, Answering questions from staff/student/parents, Following up on effectiveness of device, etc.
Name:Job Title:
Phone/email:
REPAIRS
Describe any extended warranties available (timeline, cost, what is covered, etc. If the device needs to be repaired, what is the procedure?
If the device needs to be repaired, what is the procedure?
How long will the repairs take (average turnaround time)?
Will a loaner be provided while the repair is being done?
If a loaner cannot be provided, how will the student’s needs be accommodated?
Is there a repair shop in your area?
What is the cost?
Upon purchase, what training does the company provide?
Assistive Technology Proposal for Device Purchase
Is there ongoing maintenance/upgrading required?
Who will maintain/upgrade the device?
Who will provide the student with support/training?
Assistive Technology Proposal for Device Purchase Breakdown of Cost: Signatures of Team Members:
For Kalamazoo RESA Assistive Technology Team Use Only
Will the parent’s private insurance policy cover the cost of the device? NO
What, if any, third party funding sources have been explored – Lions/Lioness Clubs, Kiwanis, MRS, ELK, etc.? NO
Reviewed and approved by Kalamazoo RESA Assistive Technology Team:
Date ______Signature ______