FNESC/FNSA Special Education#113 – 100 Park Royal South

West Vancouver, BCV7T 1A2

P: 604-925-6087Toll Free: 1-877-422-3672

Fax: 604-925-6097School Information Handout

2015-2016 FNESC/FNSA SPECIAL EDUCATION PROGRAM Second Level Services Applications

FNESC/FNSA Special Education Program (SEP) services are led by a multidisciplinary team whose mandate is to provide educational support services to students with special needs in BC First Nations schools.

What educational support services are available?

SEP staff are available to travel to schools, given time and resource availability, to provide on-site support to help meet the needs of students. Supports include:

Assessment Consultation Intervention Assistive Technology Inclusion Transition planning In-service

Who Provides SEP Services in Schools?

The SEP Team consists of SEP Managers Holly Smith (Northern BC) and Madeline Price (Southern BC), SEP Coaches, Speech Language Pathologists, Psychologists, and a SET-BC Assistive Technology Consultant.

What resources are available on the SEP Website?

Additional information is available at www.fnsa.ca and www.fnesc.ca, including the SEP forms required for accessing services and funding.

Who are the FNESC Office SEP contacts?

Barb O’Neill, Senior Administrative AssistantTel (604) 925-6087 Fax (604) 925-6097

Holly Smith SEP hollys@fnesc.ca or Toll Free 1-855-250-5083

Due date for Application Forms – May 29, 2015

Accessing FNESC Special Education ServicesOVERVIEW

School Request Form for FNESC/FNSA SEP ServicesIf you require FNESC/FNSA SEP services, please complete the School Request Form, ensuring you check off all of the services you are requesting and the service forms you will be submitting.  Once this School Request Form and the relevant service referral forms are completed, please forward to FNESC office prior to May 29, 2015.

Speech Language Pathology (SLP) ServicesThe SLP service delivery model is as follows.

Schools can submit applications for SLP services. Applications will be reviewed based upon the students’ speech language needs. For applications that are accepted, support will be provided in one of two ways:

o A FNESC employed SLP will visit schools that cannot access an SLP on their own; oro For schools that can access a SLP locally, SEP funding will be provided to reimburse

schools for the SLP services, using the established FNESC SLP payment rate.

To request this support, applicants must complete the SLP referral checklist for each relevant student, along with a signed parental authorization for release of information form. The parental authorization for release of information forms MUST be signed in order for any student to be considered for service/funding.

Psycho-Educational AssessmentsIf you wish to refer a student for a psycho-educational assessment, please review the Guidelines for Psycho-Educational Assessment Referrals prior to applying. If a student is eligible, fill out the Psycho-educational Assessment form, along with the Parent/Guardian Authorization for Release of Information for each student you are referring. Also include any relevant supporting documentation (i.e. psychological/psychometric, speech-language, vision, hearing, achievement/academic, Occupational Therapy assessments, SMART Goals, etc.). Current students who have been approved for the High Cost Additional Funding and who require re-assessment will be considered first priority.

SET-BC Assistive TechnologyPlease note there are significant changes in SET BC service delivery model for the 2015-16 school year. No students will be carried forward on the services list from 2014-15. Only very few students with complex needs will be considered for individual solutions at the Tier 3 level. Please attend a webinar on May 13th at 10:00 am on the new service delivery model. Topics will include; determining if students meet individual criteria and opportunities for classroom based projects. If a student meets the new criteria for SET-BC services, please fill out the SET-BC forms.

School Special Education Support ServicesIf you require further information, or if you need to schedule special education support services such intervention planning, Individual Education Plan (IEP) development, DIBELS training, etc., please contact the SEP Manager in your area.

When all forms are complete, please scan and return them to Barb O’Neill at barbo@fnesc.ca or mail them to the FNESC office.

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Guidelines for Psycho-Educational Assessment Referrals

This document is meant to provide some guidelines to help the schools decide which children should be referred for Psycho-Educational assessments.

What is a psycho-educational assessment?

There are different types of psychological assessments that employ a variety of techniques aimed at better understanding each particular individual’s needs. The assessments are designed to respond to the referral question, so the types of assessment procedures chosen by the psychologist are determined by the perceived problem.

Most psycho-educational assessments are conducted with school-aged children, in response to referrals about problems that the child is experiencing.

Most psycho-educational assessments explore multiple domains, including: o Cognitive and academic functioningo Language and communicationo Long term and working memoryo Attention and activity levelo Executive functioning/self-regulationo Adaptive functioning/life skillso Social development and emotional functioningo Visual-perceptual/motor/sensory functioning

In order to explore all of these domains, the psychologist normally gathers information from multiple sources, such as direct testing (cognitive, academic, memory, language, etc.), observations (in class, during testing, on the playground), interviews (parents, teachers), rating scales (adaptive skills, executive functioning, behaviour), work samples, report cards, anecdotal reports, etc.

Once psychologists have collected sufficient information about the child, they will hold a debrief meeting with parents, teachers, administrators, educational assistants, and other professionals who work with the child (e.g., pediatrician, speech-language pathologist, occupational therapist, counsellor). These meetings will result in a productive sharing of ideas, further information sharing with the psychologist, as well as discussion of applicable diagnoses and recommendations for supporting the student at school and at home.

The psychologist completes the assessment with a written report, copies of which are sent to the people who need them, including the school, parents, and outside agencies if consent is provided by the legal guardian. These reports are confidential and are to be kept safely in locked cabinets at school, with access provided only to individuals who need the information to support the student.

The psycho-educational assessment report is meant to be helpful for the child. The recommendations are generally geared toward supporting students at school, and should be in keeping with the guidelines for special education support established by each school.

The psychologist will make diagnostic statements that either confirm or rule out whether the child meets the criteria for various types of support. This includes the Ministry of Education criteria for a special education category, the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for a disorder, and/or the FNESC/FNSA/AANDC guidelines for

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support. They may include statements about other types of support that could be available to the student, either immediately or in the future, such as Ministry of Children and Family Development’s (MCFD) Children and Youth with Special Needs, Community Living BC, Fetal Alcohol Spectrum Disorder (FASD) Keyworker, Provincial Outreach Program for Autism and Related Disorders (POPARD) support for Autism Spectrum, etc.

What are potential benefits of an assessment?

Better understanding: The main goal of the assessment is always to provide the child’s team with ways to support them in school. The assessment should reveal information that was previously not known about the child, so that everyone has a better understanding of the child as a learner, and to help the team to make adjustments to better suit the child’s differences. A diagnosis of a disorder or special need may be made.

Extra supports: If a child is found to meet the criteria for any special needs classifications, the student may have access to additional support, including potential additional funding. For students who transition to a public school, access to services may depend upon meeting the criteria for Ministry of Education classification. This is one reason why psychologists attempt to determine if the student would meet those criteria.

Outside Services: Similarly, there are services provided by outside agencies that are only available to individuals who carry diagnoses. Students who are eligible for extra services, for which a psychology assessment is a significant part of the classification process, include those who have:

o Intellectual Disabilities (IQ and Adaptive Functioning below 70),o Learning Disabilities (IQ is average or higher, academic skills significant delayed)o Gifted (high IQ, or other evidence of exceptionally high potential)o Autism Spectrum Disorder (must be diagnosed by ICAAN assessment team, but can

include the information provided by our psychologists)o Chronic Health Impairment (includes Fetal Alcohol Spectrum Disorder, which must be

diagnosed by a team including a psychologist)o Students requiring Moderate or Intensive Behaviour Support and/or Mental Illness

(psychology assessments form part of the designation criteria)

Which students should be assessed, and timing of assessment?

Students of any age can receive a psycho-educational assessment, although FNESC will only fund the assessments for students up to 21 years of age, and usually after the child has received significant levels of intervention in the early grades.

Primary: Assessments for children in the early grades can be appropriate, if the student appears to be meeting one of the following key categories.

o If a child seems to have intellectual disability, they could be referred for psycho-educational assessment early (grade one or two).

o If the child presents autistic-like characteristics, he/she should be referred to a family doctor and/or paediatrician to begin the process of the BC Autism Assessment Network (BCAAN) multidisciplinary assessment, which can often take a minimum of one to two years. A psycho-educational assessment could be helpful in supporting the referral for the BCAAN team, and sometimes reduces the wait time, but it is not necessary for a diagnosis.

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Intermediate: Students in grades 3 to 8 are the most frequently referred and assessed.

o If the child presents with delays in reading, writing and/or math, but seems to have sufficient intelligence to understand everyday materials, he or she may have a learning disability (LD). Such children usually should be referred only after they have been provided with sufficient intensive interventions.

o Students with persistent “behaviour” problems should have assessments to rule out learning problems as a cause of their challenging behaviour.

Secondary:

o Students who present with LD (either previously diagnosed or suspected) should be referred for an updated assessment prior to the provincial exams beginning in grade 10 to ensure that they qualify for adjudication adaptations, including a reader, scribe, technology, or extra time.

o The assessment in the secondary school years can also support an LD student’s application for similar adaptations and support in post-secondary institutions for five years after the assessment is completed.

o Students diagnosed with Intellectual Disability can be eligible for services from Children and Youth with Special Needs, a branch of MCFD, until they reach 19 years of age, and then from Community Living BC. The Ministry responsible for CLBC is now requiring the schools to confirm a diagnosis meeting the DSM-IV-TR criteria for “Mental Retardation” and/or DSM-5 criteria for “Intellectual Disability” by the time the student is 16 years of age. This “confirmation” may require an updated psycho-educational assessment, depending upon the time since the previous assessment, and/or the confidence with which the previous diagnosis was made.

Adults:

Assessments for adults can be appropriate if they have never been previously assessed and may be entitled to support if they were to receive a diagnosis. The main areas of support available to adults includes Community Living BC, which provides considerable funding and support for adults with Intellectual Disabilities. FASD Keyworkers and CLBC supports are also available to students carrying a diagnosis of FASD.

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FNESC/FNSA SEP Services Request Form

School: ______________________________________________________________________

Principal: _________________________________Email: ______________________________

SEP Contact _______________________________ Email: ______________________________

Address: ________________________________ Town: _______________________________

Postal Code: ___________________________

Phone: ________________________________ FAX: _________________________________

Request for Service

Psycho Educational Assessments (Psych Ed) SET-BC Assistive Technology

For Speech Language Service Request Please check ONLY one box: FNESC Speech Language Service (SLP) OR Speech Language Funding Assistance, SLP Name: ________________________________

Number of students referred last year______Number of new referrals ______

Please complete an application form for new referrals only.

This form, along with the following documents, completes the request package (please ONLY include and check off forms for the services you are applying for)

Speech Language Pathology (SLP) Service School Request Form Speech Language Pathology (SLP) Student Information Form SLP Parent/Guardian Authorization for Release of Information Psycho-educational Assessment Request Form Parent Authorization for Psychological Assessment SET-BC Referral Form SET-BC Parent/Guardian Authorization for Release of Information

Name of person filling out the Form: (please print) __________________________________

Principal (or designate) Signature: ________________________Date: ___________________

Return to: Barb O’Neill, Special Education Program

FNESC/FNSA INFORMATION ONLY – DO NOT Complete

DATE RECEIVED: _______________________________ DATE LETTER SENT: ________________

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FNESC/FNSA SPEECH-LANGUAGE PATHOLOGY REFERRAL FORM

SCHOOL: …………………………………………………….. Date of Referral: ……………………

STUDENT’S NAME: ………………………………………… Date of birth: …………………….….

Date of IEP: …………………………………………..……… Current Grade: …..………………..

Previous assessments completed / date:

☐ Vision: ………………….. ☐ Hearing: ……………………..☐ Psychology: …………………..…..… ☐ Speech-Language Pathology: ……..…….………..…☐ Occupational Therapy: ..……..….… ☐ Academic Achievement: ………………...…..…..……

What concerns do you have about this student’s speech, language and communication skills?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________’

What information do you hope a SLP assessment will provide?______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Person completing form: ____________________________________________ Title: ___________________________________________

Signature: _____________________________________________________ Date: ____________________________________________________

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FNESC/FNSAParent/Guardian Authorization for Release of Information

Student Name: ___________________________________

Date of Birth: ____________________________________

Authorization

I understand that an application is being made to the First Nations Education Steering Committee (FNESC) and First Nations Schools Association (FNSA) for Speech Language Pathology services for my child. As part of that application, I understand that the School, ________________________, must provide information about my child to FNESC and FNSA for evaluation. That information may include information about my child’s special needs, medical and educational history, Individual Education Plan, testing and assessment results and similar information. I understand that the information will be used by FNESC and the FNSA for the purposes of making a decision about providing additional funding for services for my child. I understand why I have been asked to release information and am aware of the risks or benefits of consenting or refusing to consent to release this information. I understand that all information will be treated as confidential by FNESC and FNSA, but that it will be disclosed within FNESC and FNSA to those individuals who are considering the funding application. I also understand that I may revoke this consent at any time by submitting a written revocation document to FNESC. I understand that if I do not consent to the release of this information my child may not receive the support services that would be funded by this application.

□ Yes □ No I authorize release of school records to FNESC and the FNSA, including the records described above, concerning my child for the purpose of my child’s school applying for Speech Language Pathology Services/resources for the above. The records should be directed to:

Special Education Program, First Nation Education Steering Committee &First Nations Schools Association#113 – 100 Park Royal SouthWest Vancouver, BC, V7T 1A2Tel (604) 925-6087Fax (604) 925-6097

Signature of Parent/Guardian: ________________________________________

Name of Parent/Guardian (please print): ________________________________

Date: ____________________________________

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FNESC/FNSA SEP REFERRAL FORMfor Psycho-Educational Assessments

SCHOOL: …………………………………………….. Date of referral: ……………………STUDENT’S NAME: ………………………………… Date of birth: …….………………...Parents/Guardians: ………….……………………… Telephone: …………………………Classroom Teacher: ………………………………… Current Grade: …………..………..

Attach previous assessments that have been completed, with date:

☐ Psychology: ………………….…… ☐ Speech-Language Pathology: …………..……☐ Occupational Therapy: ..………… ☐ Academic Achievement: …..………………….☐ Vision: …………..…….. ☐ Hearing: ………..………... ☐ Other: ……………..……..

Reason for Referral: What are the major concerns, questions about this child?

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

How long/often has this student been having these difficulties?

………………………………………………………………………………………………………

Describe the types and frequency of interventions/supports that you are using to support the child (e.g. small group, visual schedules, pre-teaching before the lesson, double dosing core programs, school counsellor, social stories, etc.)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Child's learning style: (activity level, attention, organization, impulsiveness)………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Student’s personal characteristics, health or home background:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

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Child’s behaviour:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Child’s attendance over the past few years (approx.%):………………………………………………………………………………………………………

Describe the child’s academic development/performance:………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Child's fine and gross motor skills compared to age expectations:………………………………………………………………………………………………………

Child's speech and language skills compared to age expectations: ………………………………………………………………………………………………………

Child’s special interests or talents:………………………………………………………………………………………………………………………………………………………………………………………………………………

Describe his/her social interaction with other children and with adults:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

Parent/school relationship: (Are parents involved, concerned, aware of difficulties?)………………………………………………………………………………………………………………………………………………………………………………………………………………

Any Medical conditions/Medications:………………………………………………………………………………………………………

Additional Comments:

………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………

***Note: Please submit any SMART goals developed for child along with this form***

Thank you for your caring support for this student!

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PARENTAL AUTHORIZATION FOR PSYCHO-EDUCATIONAL ASSESSMENT & DISCLOSURE OF INFORMATION

After consideration by the school team and in consultation with you, it has been determined that a psycho-educational assessment would be beneficial in supporting your child;

______________________________________ at _______________________________ School.

Purpose of AssessmentThe main purpose of assessments is to help teachers and parents best support the student in school.

Assessment ProcessThe psycho-educational assessment may include: Information from parent or guardian. Observations conducted by school personnel on ability, achievement, behaviour and

attendance. Testing by a qualified school psychologist, which may include measures of: Intellectual

Ability, School Achievement, Perceptual Abilities, Adaptive Functioning (i.e., life skills), Behaviour (i.e., attention, self-concept, social and/or emotional functioning)

If you have any questions about the psycho-educational assessment, you may contact Dr. Leonard Stanley, Coordinator at 250 752-5423 or email - lenkz@shaw.ca

OutcomesFollowing the assessment, the psychologist will discuss the findings and recommendations with the parents and relevant school staff. The psychologist will write a report, and copies will be provided to the parents/guardians and put in the student's school file.

For some students, assessment findings may assist in identifying various learning difficulties as referenced in the Diagnostic and Statistical Manual of Mental Disorders - Fourth Edition. If a student meets criteria as a student having special needs, additional services may be recommended.

Voluntary Consent

1. Consent for Referral - The school would like your consent to refer your child for assessment to FNESC – Special Education. The FNESC special education team will determine if this referral will be included among the limited number of assessments available to First Nations schools in BC.

2. Consent for Assessment - If your child is selected for assessment, the school would also like your consent for the assessment itself. Dr. Leonard Stanley, along with his psychology team, will coordinate the assessment with the school and FNESC.

If your child is not selected by FNESC for assessment during this upcoming school year, the consent must be renewed for any future referral in the future. Authorization and participation in the psychological assessment are voluntary.11 | P a g e

Right to WithdrawThe parent/guardian/independent student will be notified in advance when the assessment is to take place and they may revoke this consent at any time by notifying the principal of the child’s school.

Confidentiality Information will be strictly confidential. Results will be used in the school only by those responsible for developing a support program for your child. The psychologist will keep a confidential copy of your child’s results and a digital copy will be housed in the FNESC office.

CONSENT

I hereby consent to have my child, ______________________________________,

Please check boxes to indicate your consent for the following:

REFERRED FOR POSSIBLE ASSESSMENT - I understand that the FNESC/FNSA special education team will examine information to determine if my child should be assessed during the upcoming school year, but that they may not select my child for assessment this school year.

CONSENT FOR ASSESSMENT - If my child is selected, I hereby consent to have my child participate in a Psycho-Educational Assessment by a FNESC approved psychologist as described above.

AUTHORIZATION SIGNATURES

__________________________ ___________ ______________________________Name of Principal or Designate Date Signature of Principal or Designate

(mm/dd/year) __________________________ ___________ ______________________________Name of Parent/Guardian/ Date Signature of Parent/Guardian/Independent Student (mm/dd/year) Independent Student

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British Columbia First Nations SchoolsProcess for Accessing SET-BC Services

School Based Referral Action Steps School Based Responsibilities

1. Teacher refers the student to the School Team.

2. School selects a school based contact person.

3. If SET-BC services are needed, the school completes the First Nations School Screening Checklist. - eligible individual students have very complex needs requiring specialized technology to access the curriculum.

4. Submit the First Nations School Screening Checklist to the First Nations Education Steering Committee (FNESC)/First Nations Schools Association (FNSA) office.

1. School Team completes the Screening Checklist. School based contact person submits the Screening Checklist to the FNESC/FNSA office.

2. If selected for technology solution, the school agrees to provide release time for the full student team for consultation and training with the SET BC consultant.

3. The school provides peripheral devices (eg printer, scanner) and consumable items as required.

4. Security for the SET BC loaned technology.

SET-BC MandateSET-BC is a Provincial Resource Program designed to assist BC School Districts in meeting the technology needs of students with physical disabilities, visual impairments and autism. SET-BC’s mandate is:

1. to loan assistive technologies (reading, writing, and communication tools) where those are required to ensure students’ access to educational programs, and

2. to assist School Boards in providing the necessary training for students and educators in the use of these technologies.

In 2007, the First Nations School Association membership agreed to use a portion of the BCSpecial Education Program (SEP) funding to enter into an agreement with SET-BC for the provision of services to students in First Nations schools with special needs that fit within the SET-BC mandate.

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FNESC/FNSA and SET-BC Agreement

First Nation School Screening Checklist

for SET-BC Service

Student Name:      Submitted By:      

Due Date:

2015/05/29 Date Submitted:     YY / MM / DD

Please Return form to:

First Nations Education Steering Committee (FNESC) Attention: Barb O’Neill

Suite 113, 100 Park Royal South, West Vancouver BC T2A1A7

Tel: 604-925-6087 Fax: 604-925-6097 Email: barbo@fnesc.ca     1. Student Information:Student is currently using SET-BC Assistive Technology Yes No Student is currently using Assistive Technology Yes No

Surname Given name(s) Birth Date (yy/mm/dd)                 Home Address (Complete Mailing Address)

     

SET-BC / District Partner use only Service Points      

City:     

Postal Code     

Grade:     

Gender M F

1.2 Student Status Information:Student is reported as: Deaf/Blind (DB) physically handicapped /chronic health (PH) dependent handicapped (DH)

autistic (AUT) moderate to profound (MP) visually impaired (VI)

Type of Impairment (Check those that apply) motor vision communication cognitive

Disability Diagnosis:     1.3 School Information:Key School Contact Person:     

Position:     

Email:     

Telephone:     

Facsimile:     

Name of School:      

School Telephone:     

School Facsimile:     

School Mailing Address:     

City:     

Postal Code:     

Classroom Teacher:     

School Principal:     

Teaching Assistant:     

Classroom Teacher Email:     

School Principal Email :     

Teaching Assistant Email:     

1.4 Parent Guardian Information:Parent / Guardian Name:     

Email:     

Telephone (Home)     

Complete Mailing Address :     

Postal Code:     

Telephone (Work)     

Foster Parent Family Name (if applicable):     

Email:     

Telephone (Home)     

Complete Mailing Address (if applicable):      

Postal Code:     

Telephone (Work)     

1.5. Referrals and Services Received:Special Education Services Received: (please check all that apply)

Speech / Language Services Services for the Visually Impaired

Physical / Occupational Therapy Services for the Hearing Impaired

Has this student been referred to and/or received services from other programs? Please name program and specify year.     

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2. Student Profile complete relevant sections only2. 1. Cognitive / Academic Level:Cognitive Level: (based on psycho-educational assessment)

above average average mild delay moderate delay severe / profound delayAchievement Level:      

not yet meeting minimally meets fully meets exceedsreading

reading comprehension written language math / numeracy

Pre-academic skills:(describe if applicable) Recognizes objects photos line drawings      

choice making ability:      visual matching skills:      

2.2. Motor Skills No ConcernsMobility: walks independently

manual wheelchair self propels non propellor

walker power wheelchair crutches/cane other (eg. crawls.)

     Typing Speed       WPM

Hand Use (dominance & function):

right hand age appropriate

left hand impaired/delayed

both not functional Comment::     

Please rate student use with the following scale: B = beginner SP = some proficiency P = proficient NA = not applicableB SP P NA B SP P NA B SP P NA

regular keyboard regular mouse

joystick trackball

regular pencil adapted pencil grip alternate keyboard

(specify type)      

head pointer hand switch head switch

switches alternate site Physical needs:

scribing extended time reduced workload writing samples attached2.3. Vision No Concerns

Visual Impairment:

low vision totally blind visual field restrictions

cortical visual impairment colour vision deficit progressive

Acuity       right eye      left eye      both eyes

Reading Medium:

Braille large print (lp) lp with speech support auditory only

large print (preferred font size)      

Braille:           uncontracted                contracted

Student Ability:

typing speed       Optical Aids Used      low vision clinic (include report) preferred magnification      

2.4. Communication No ConcernsSpeech/Language: speaking articulation difficulties language difficulties

non-speaking: communicates by (explain briefly below) sign language       gesturing/pointing       communication boards/books       Picture Exchange Communication

System       simple speech output device (Big Mac)       dedicated voice output communication device       other (specify)      

What is the student’s primary mode of communication?      

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2.5. Social / Behavioural No ConcernsPlease Describe:

peer interaction       time on task / attention span       work productivity       impulsivity       safety issues       no concerns      

2.6. Access to Curriculum (student snapshot)What barriers prevent this student from meeting reasonable educational goals?     What non-technical and / or technical strategies have been investigated or put in place to overcome the barrier(s)?     Please indicate and comment on the student’s willingness to use technology and on his / her technology preference.     3. Educational Program: List 1 primary goal. Two additional goals may be recorded.The student’s educational program is modified adapted other (explain)     

Technology will be used: in class, in resource room, in multiple locations.Estimate frequency of technology use a in the student’s program

occasionally (1-2 times per week) on a daily basis (up to one hour per day)

frequently (3-5 times per week) almost continually (3-5 hours per day)

Please list the primary educational goal that will be supported through the use of technology. Include current level of functioning (baseline statement) and how progress will be measured specific to the affect of A.T.: (attach copy of IEP) Goal 1:      current level of functioning:      evaluation criteria:      Goal 2:      current level of functioning:      evaluation criteria:      Goal 3:      current level of functioning:      evaluation criteria:      4. School TeamPlease indicate your School Team’s readiness to implement technology:Technical Skills/Support

o School Team’s technical skillso Access to tech support within the school

beginning limited

intermediate adequate

advanced occasionally

School Support

Availability for meetingsRelease time for trainingPurchase of peripherals (printer, scanner)Purchase of consumables (printer ink, etc.)Purchase of educational\productivity softwareSchool based transition plans

limited limited limited limited limited limited

adequate adequate adequate adequate adequate adequate

easily met easily met easily met easily met easily met thorough

(not supplied by SET-BC)

Will the student be transitioned to a new team or new school next year? yes no Please comment      

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4.1 School Team:Please list school personnel involved with this student

Job Role Name Aware of this referralParent/Guardian       yes no

Classroom Teacher       yes noResource Teacher       yes no

Speech/Language Pathologist       yes noAugmentative Communication Consultant       yes no

Vision Teacher       yes noOccupational Therapist       yes no

Physiotherapist       yes noTeaching Assistant       yes no

Counselor       yes noOther       yes no

5. Technology ConsiderationsWhat computer platform is currently in the school? Macintosh Windows Are there other SET-BC computers in the school? Yes NoHow is the student currently accessing computers in the school? (include location and frequency of access)      What type of technology is currently in place for the student? (include hardware and software)      What type of technology has been recommended / are you considering requesting from SET-BC ?

Portable word processor Computer Talking word processing software Word prediction Picture processor Integrated scan/read/write software

Alternate access

Screen magnification Screen magnification with speech CCTV Print to Braille software and Braille printer Screen reader Refreshable Braille device

Augmentative and alternative communication software Augmentative and alternative communication device Other      

Attached Documents:Please list attached documents:     

NOTES:      

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Successful selection and implementation of Assistive Technology may include:

effective consultation including student input, to ensure a good match of technology features to student need

clear educational goals and a clear idea of how technology will support those goals adequate time for School Team planning, training and follow-up training the School Team sharing responsibility for solving problems, creating overlays/templates,

monitoring use, etc. integration throughout the daily schedule adequate practice time for the student adequate funding for purchase of necessary peripherals (printers, scanners) or consumable

items (printer ink, batteries, etc.) coordinated maintenance and support

SET-BC provides: consultation services to match technology to student needloan of assistive technology to First Nation schools for the use of eligible students

(software and/or hardware) school team training, follow-up training and re-training implementation resources technical support to maintain and repair SET-BC equipment

School Team undertakes to provide: release time for consultation, planning meetings, follow-up training and retrainingperipheral devices (printers, scanners) and consumables as needed access to additional educational software required, e.g. MS Wordsafekeeping of the SET-BC loaned technology

School Team Commitment:I have read the suggested guidelines for successful implementation of assistive technology and I understand the School Team’s responsibilities. Should my student be allocated SET-BC service, I am committed to providing time and the resources listed above to successfully implement the assistive technology.

School Principal Signature Date

School-based Contact Signature Date

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FNESC/FNSAParent/Guardian Authorization for Release of Information

Student Name: ___________________________________

Date of Birth: ____________________________________

Authorization

I understand that an application is being made to the First Nations Education Steering Committee (FNESC) and to the First Nations Schools Association (FNSA) for SET-BC services for my child. As part of that application, I understand that the School, ________________________, must provide information about my child to the FNESC and FNSA for evaluation. That information may include information about my child’s special needs, medical and educational history, Individual Intervention Plan, testing and assessment results and similar information. I understand that information will be used by FNESC and the FNSA for the purposes of making a decision about providing additional funding for services for my child. I understand why I have been asked to release information and am aware of the risks or benefits of consenting or refusing to consent to release this information. I understand that all information will be treated as confidential by FNESC and FNSA, but that it will be disclosed within FNESC and FNSA to those individuals who are considering the funding application. I also understand that I may revoke this consent at any time by submitting a written revocation document to the FNESC. I understand that if I do not consent to the release of this information that my child may not receive the support services that would be funded by this application.

□ Yes □ No I authorize release of school records to FNESC and the FNSA, including the records described above, concerning my child for the purpose of my child’s school applying for Special Education SET-BC Services/resources for the above. The records should be directed to:

Special Education Program, First Nation Education Steering Committee &First Nations Schools Association#113 – 100 Park Royal SouthWest Vancouver, BC, V7T 1A2Tel (604) 925-6087Fax (604) 925-6097

Signature of Parent/Guardian: ________________________________________Name of Parent/Guardian (please print): ________________________________Date: ____________________________________

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