Application Form – Engaging in Eye Gaze: Collaborating and Consulting with Schools
Please note: This form contains multiple sections (A to D). Please complete the ‘supports applying for’ section below, and only complete the corresponding parts.
What supports are you applying for: (please cross the appropriate box)
☐ A clinic day using ILC’s project equipment to trial eye gaze with up to 5 students:
-(Complete Part A Part B)
☐ A training session to support the use of our school’s existing eye gaze equipment:
-(Complete Part A Part C)
☐Support and training to setup the Unlocking Abilities Eye Gaze Kit (Hired from ILC):
- (Complete Part A & Part D)
☐ Interested in finding out about additional supports beyond the scope of this project
-Call the ILC enquiry line on 9381 0600 or email requesting more information regarding eye gaze technology.
PART A:
Date of Referral:Name of person completing this form:
School
Name: Phone:
Address:
Staff Parking details:
Principal/ Deputy: Principal/ Deputy email:
Other key staff: Email:
Other key staff: Email:
Availability
Clinics and onsite school support options will be completed on Mondays, Wednesdays and Thursdays within March, April and May. Are there any days that it would NOT be suitable to provide onsite support for your school?
Your school and students
Please describe the cohort of students who attend your school. How many students have alternate access needs (have difficulty using their hands to point and use materials)? How many students have complex communication needs (have little or no speech, or speech doesn’t meet their needs)?
Learning technologies
Please describe the equipment and software your school already use to support student access and learning (e.g. iPads, desktop computers, switches, eye gaze equipment, Boardmaker, Clicker, AAC apps or devices etc.)
What are you hoping your schoolwill achieve by participating in this program?
How accepting do you feel school staff are of having students using alternative methods of accessing technology at school?
Support for Referral
I support the referral of (school name) into the program and I consent to be part of the program.
Principal
Name:Signature: Date: //
Deputy Principal
Name:Signature: Date: //
Class teacher (Include as many key teachers as relevant)
Name:Signature: Date: //
Class teacher
Name:Signature: Date: //
Class teacher
Name:Signature: Date: //
Class teacher
Name:Signature: Date: //
Please attach any further information to support this application e.g. IEP plans, assessment reports, school plan.
END OF PART A
Application form – Engaging in Eye GazePART A – ALL TO COMPLETE
PART B: Eye gaze clinic application
(complete this section if you are applying to have a clinic day trial with ILC’s project equipment)
Please describe any experience your staff or students currently have with using eye gaze?
What area within your school would be suitable to hold the eye gaze clinic (preferably a space with few distractions and enough space for equipment and several people).
Please complete the below information table for students you are applying to include in the clinic (up to 5 students).
Student name / DOB / Diagnosis / How does the student currently communicate? (i.e. spoken key words, AAC device etc) / Does the student currently access a computer or tablet device? If yes, how do they access the device? (switch access, clear finger point etc)//
//
//
//
//
Please note: if you are successful in your application, additional student information will be requested.
What learning outcomes or activities are you hoping your students may be able to achieve or access using eye gaze?
END OF PART B
Application form – Engaging in Eye GazePART B
PART C: Support to use your school’s existing Eye Gaze equipment
Please note the specific eye gaze equipment your school owns:
Please note the software you are currently using with your eye gaze equipment:
How do you currently position your eye gaze equipment (e.g. on an adjustable table, desk mount, rolling floor mount)?
What training and support have your staff already accessed around eye gaze?
What support or training are you hoping to access to assist your staff to improve access and learning outcomes for students using eye gaze?
END OF PART C
Application form – Engaging in Eye GazePART C
PART D: Support to hire, setup and use the Unlocking Abilities Eye Gaze Kit
- Applications to hire this equipment are dependent on hire availability.
- Please note: The all in one computer in this kit has limited mounting and positioning options. If you have students who have more complex positioning needs (e.g. need to be very reclined) please discuss the options of other equipment in ILC’s hire library.
Please describe any experience your staff or students currently have with using eye gaze?
What support or training are you hoping to access to assist your staff to improve access and learning outcomes for students using the hire equipment?
How many of your students are you hoping to use the eye gaze equipment with?
What learning outcomes or activities are you hoping your students may be able to achieve or access using eye gaze?
END OF PART D
Application form – Engaging in Eye GazePART D