Iowa Education Services for the Blind and Visually Impaired
Assistive Device Center Checkout Form
Student Name:
TVI/OMS Name:
School District:
Date of Request:
Reason for Checkout (assessment, during a class offered by IBS, repair of student equipment, result of Low Vision Clinic Recommendation, Other:
Equipment requested:
Post-Checkout Information:
Please provide the bolded information on CRM in the AT Assessment Section in the Notes. Please answer and copy and paste to CRM-AT Assessment-Notes for the particular student.
Will equipment be purchased as a result of the assessment conducted with trialed equipment?
If yes, what equipment is being purchased?
Is additional equipment needed for assessment?
If yes, explain.
An ADC checkout form must be completed if additional equipment is needed.
Other Comments:
Policy and Procedure:
1. Check out is for 6 weeks for assessment purposes.
2. Checkout of equipment may be made while student equipment is out for repair.
3. If circumstances require checkout longer than 6 weeks, please contact the AT Consultant (Chad).
There is often a waiting list for equipment, so timely return of equipment is appreciated.
4. When equipment is not returned in a timely manner, the Regional Director will be contacted to assist in resolving the situation.
5. Requests for checkout of equipment will not be filled if a checkout form is not received by the Assistive Technology Consultant.
6. If you are planning to use equipment for more than one student, a checkout form should be sent when the transfer of equipment is made. Approval for this checkout is required by the Assistive Technology Consultant based on requests by other TVIs and waiting lists for equipment. Continued use of equipment may be denied if others have requested equipment.
7. Assistance with setup, demonstration of equipment, and consultation regarding assessment is available on request. Call or e-mail Chad Brown.
8. It is strongly recommended that you don't request equipment if you know assessment cannot start promptly. When equipment sits on the shelf untouched, this means a longer wait time for someone else.
9. After trial of equipment for assessment purposes, the Local Education Agency is responsible for ordering and purchasing assistive technology.
10. The Local Education Agency is responsible for the cost of maintenance and repair of LEA purchased assistive technology.
This form should be sent to:
Rosa Mauer
563-320-6255
https://sites.google.com/site/assistivetech1/
See next page for optional signature documentation.
Iowa Education Services for the Blind and Visually Impaired
Optional Signature Documentation Page
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______