WSSB Statewide Assistive Technology Program Visit

Bruce McClanahan: 360-947-3360

Please fill out this form and submit it.  I will be emailing you the week before the visit to confirm the appointment.  Please reply to this email if there are any changes or if the appointment has been cancelled.

Write N/A if it does not pertain to the visit.  Please fill out at minimum items 1-4.


1. Assistive Tech Visit (Name, Date and Time Scheduled)

Teacher First Name: Last Name:

Month: Day: Year:
Hour: Minute: AM/PM:

2. Address

Street:
City:

School:

3. Equipment and Objectives to Cover (Please list the equipment I should bring with me; Macintosh computer, Windows computer, desktop video magnifier, iPad, iPad switches, IntelliKeys, Chromebook, etc.)


(If Other: )

4. Emergency Contact *Skip if already completed this school year

Name :
Phone:

5. Windows or Macintosh School District?


(If Other: )

6. Is your school district a Google Drive District, Office 365 District, other?


(If Other: )

7. Does your school district use Braille Notetakers, Braille Displays? (Please specify device) *Skip if already completed this school year

If yes:

8. iPad Switch Access, IntelliTools, other software for visually impaired students with significant additional impairments? (Please specify device)*Skip if already completed this school year

9. Evaluation (The WSSB Statewide Technology Project is evaluated by a short survey at the end of every school year.  Please provide the names and emails that this survey can be emailed to.)*Skip if already completed this school year

a. Name: Email:
b. Name: Email:
c. Name: Email:

10. Comments: