High School/High Tech, a program of the Vocational Rehabilitation Program, is awarding laptop computers to eligible students in your school. To be eligible to receive a computer to use during the school year, each student must submit one referral form from the Teacher or Vocational Rehabilitation counselor. Please respond candidly and thoroughly to each question; the evaluation panel places considerable emphasis on the teacher referral.

Please complete the form below and return to


(Site Coordinator) (Date)

Student Name ______Grade______

School System ______School ______

Teacher’s Name ______Class Taught to Student______

Teacher’s Phone ______Email address ______

Vocational Rehabilitation Counselor______Phone #:______

1.  How long have you known this student?

2.  What are the student’s strengths?

3.  What are the student’s challenges?

Teacher\VR Referral Form, Page 2

Student’s Name:______

4. Please explain why you believe this student would be a good candidate to be awarded a computer, and elaborate about the ways in which you think the student will benefit from its use. (Attach extra pages if necessary)

5. Please give examples of how responsible you know this student to be.

6. Do you think this student needs assistive software for the computer? Yes No

If yes, please check the area that the student needs assistance with below:

Student needs software to help with Reading, Writing, Organizing,


A standard computer is difficult for the student to use – they need help in these areas:

Help to use the Keyboard, Help to use the mouse

Student needs help using the computer screen: Low vision, Blind, Deaf or hard of hearing

Please circle the correct number for each item.

3= Almost always 2= Sometimes 1= Almost never/seldom

The student:

Takes pride in his/her work 3 2 1

Completes assignments 3 2 1

Works cooperatively with peers 3 2 1

Is motivated 3 2 1

Is respectful 3 2 1

Follows school rules 3 2 1

Teacher’s or Counselor Signature______Date______