CEO MINOR GRANTS - APPLICATION FORM

ASSISTIVE TECHNOLOGY

01 / Student Information
Student Name: / Date of Birth: / Click here to enter a date. / Year/Grade: / KindergartenYear 1Year 2Year 3Year 4Year 5Year 6Year 7Year 8Year 9Year 10Year 11Year 12
Gender: / MaleFemale / Date of Application: / Click here to enter a date.
Teacher: / Teacher’s email:
School: / If other specify:
Name of approved Assessor/Health Professional:
Organisation/Profession:
02 / Eligibility
Does the student attract SWD funding? / Yes No
Priority area: a. Essential for access to curriculumb. High risk of immediate or long term injuryc. Repair or replacement of existing Technology
03 / Statement of Student need
Provide clear, concise objective information about the student and their needs and barriers to learning/participation.
04 / Learning Environment
Provide relevant school and home information including factors such as class setting/s, people who give assistance and level of support:
05 / Learning Goals and Tasks
Select and list goals from the relevant IP domain/s:
List specific tasks or short term goals – what do you want this student to achieve using assistive technology?
Tasks or short-term goals need to be SMART (specific, measurable, achievable, realistic and time framed) and centred on student learning outcomes/ access not on learning to use the technology.
  • Task/ short term goal 1:
  • Task/ short term goal 2:
  • Task/ short term goal 3:

06 / Further Training (if appropriate)
If applicable, outline further training needs (either for student or support staff) based on student educational outcomes.
Attach a detailed training planwith this application. (see Training Plan Template on InfoPoint)
07 / Recommendations of Approved Assessor/Health Professional
Please provide details of any Reports and/or quotes you have received from approved Assessor or Health Professional for specialised Assistive Technology. Attach any relevant documentation.
08 / Managing the Assistive Technology
Outline how the assistive technology would be cared for (click to use drop down menus for relevant information):
Ongoing maintenance: 1. School IT support2. Supplier support3. CEO itinerant teacher support4. N/A
Portable devices: 1. Stored in locked cupboard during breaks2. Stored on teacher's desk when not in use
Homework: 1. Goes home for regular homework tasks2. Goes home only during holidays3. Does not go home without permission4. Not applicable
Other management:
09 / Review
Complete a formal review in the context of an Individual Plan meeting approximately six months after allocation. Ongoing reviews take place during scheduled IP meetings.
Next IP meeting: Click here to enter a date.
School staff member responsible for review:
Email:
CEO Office use ONLY
Approved? / Yes No 
On trial? / Yes No 
QUOTES
Please detail the preferred quote below. Each item must be listed and priced separately:
Supplier plus address and quote number if supplied / Technology details (list and price each item separately) / Cost / GST / TOTAL
Freight
TOTAL
CEO REVIEW
Applications completed by an assessor must be reviewed by a CEO Education Officer within 12 months (this can take place within a scheduled IP meeting).
Name of Reviewer:Position:
Signature:
/ CEO, RELS, Pastoral Care and Learning Support – DN –20032013 / 1