**DeafBlind Technical Assistance* Request**

* TA is a process of providing targeted support

Missouri DeafBlind Technical Assistance Project (MoDBTAP) provides two types of TA: focused and comprehensive. A description of each is provided below.

Focused TA
Focused TA is delivered at a targeted/specific level and is based on the clearly-identified needs of family members, program/school staff, and/or administrators. Focused TA is short-term assistance designed to address a basic, single need or a small number of basic needs, and is delivered via distance technology. This level of TA emphasizes the efficacy of family/ professional partnerships in supporting child change.
Comprehensive TA*
Comprehensive TA is delivered at an intensive/sustained level and requires a stable, ongoing relationship between MoDBTAP staff and TA recipients. Comprehensive TA can be delivered onsite and/or through distance technology. It includes a purposeful, planned series of activities designed to reach outcomes that are valued by the individual recipients. Family members, program/school staff, and administrators identify and agree to a set of TA needs to be addressed as part of the TA process. This level of TA should result in changes to practices and/or operations that support increased recipient capacity and/or improved outcomes .

*Adapted from the U.S. Department of Education, Office of Special Education Program’s definition of intensive/sustained technical assistance.

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* 1. Type of technical assistance requested

FOCUSED-Distance/virtual, phone, single or limited consultation

COMPREHENSIVE- Ongoing, onsite after 1st virtual meeting/conversation with team

Not sure yet

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* 2. Information about person completing this referral:

Name:

Phone:

Email:

Agency phone:

Agency and title (if applicable):

County

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* 3. Is the person completing this referral the primary contact for MoDBTAP staff? If not, please provide the following information for the primary contact:

Name:

Phone:

Email:

Agency phone:

Agency and title (if applicable):

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* 4. Information about the child/student:

Child’s name:

Date of birth:

Name of parents/guardians:

Address:

Phone:

Primary contact email

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* 5. Information about the school the child attends if the child is school age:

School name:

Classroom setting (general education, special education, non-public, etc.)

Name of classroom teacher:

Name of one-on-one paraeducator/intervener if applicable:

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* 6. What is the etiology related to the student's deafblindness (CHARGE, Ushers, etc)?

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* 7. Is the child receiving Occupational, Physical, Speech or other therapies?

INFORMATION ABOUT CHILD'S VISION

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* 8. Does the child have functional vision? If so, describe what you think the child can see. (Attach a recent eye report or functional vision assessment if available.)

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* 9. Eye Report/Functional Vision Evaluation/Eye information

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 10. Does the child wear glasses/contacts and/or use any assistive technology related to vision? ie magnifiers, speech output, CCTV, uses a white cane for travel?

INFORMATION ABOUT CHILD'S HEARING

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* 11. What is the auditory condition, diagnosis, or etiology?

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* 12. Does the child have functional hearing? If so, describe what you think the child can hear. (Attach a recent audiogram or functional hearing screening below if available.)

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* 13. Does the child wear hearing aids? Cochlear implant? Other assistive listening devices?

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* 14. Audiological reports/hearing assessments, medical reports on hearing

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 15. Describe the child’s expressive and receptive communication mode(s). These might include speech, American Sign Language (ASL), signed communication (i.e., single signs or signs used in English word order), voice output devices or tablets, symbols, objects, etc.

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* 16. Does the child effectively communicate wants? Needs? Emotions?

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* 17. What is the primary language used by others in the home?

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* 18. Describe the child’s gross and fine motor abilities (e.g., walking, standing, crawling, grasping, etc.). Does the child use any adaptive equipment/devices to perform everyday activities?

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* 19. Is there any additional information about the child that would be important for MoDBTAP staff to know?

AREA OF FOCUS-Check the top THREE areas that are priorities of the team at this time

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* 20. Top THREE areas of concern at this time

Understanding the impact of a combined vision and hearing loss on the child’s learning and development (SP1).

Using assessment strategies (functional vision, functional hearing, etc.) for program planning for the student (SP2).

Developing an appropriate IFSP/IEP for a student with combined vision and hearing loss (SP3).

Using effective teaming strategies with other educational professionals involved with the child with combined vision and hearing loss (SP4).

Using effective instructional strategies to implement the IFSP/IEP (SP5).

Using functional behavior analysis and positive behavior supports (SP6).

Using effective strategies to improve the student’s communication and language skills

(SP7).

Using effective strategies to improve motor development and positioning for the student

(SP8).

Using effective strategies to improve orientation and mobility for the student (SP9).

Using effective strategies to improve the student’s selfcare skills (SP10).

Using effective strategies to improve the cognitive development of the student (SP11).

Using effective strategies to improve the student’s academic and literacy skills (SP12).

Using effective strategies to improve the student’s social interaction skills (SP13).

Using effective strategies to improve the student’s self determination (SP14).

Using effective strategies to foster participation in play/recreation activities for the student (SP15).

Using effective strategies to improve the student’s community and independent living skills (SP16).

Developing age-appropriate transition planning for the student with combined vision and hearing loss (SP17).

Using strategies that improve the student’s postsecondary transition outcomes (SP18).

Appropriately using assistive technology (AT) for a student with combined vision and hearing loss (SP19).

Developing pre-literacy/literacy skills for all learners (SP20)

RESULT OF TECHNICAL ASSISTANCE. As a result of this technical assistnace, what would you like to see occur for the child. Select the top THREE areas.

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* 21. Top THREE areas that you would like to see occur from the technical assistance related to the top three areas of concerned indicated above.

Increased functional use of sensory systems/learning to use residual vision and hearing (C1).

Increased engagement in intervention and/or instructional activities (C2).

Improvement in receptive communication and/or language (C3).

Improvement in expressive communication and/or language (C4).

Improvement in positioning and motor skills (C5).

Improvement in orientation and mobility skills (C6).

Improvement in self help skills (C7).

Improvement in student’s cognitive skills (C8).

Improvement in academic and/or literacy skills (C9).

Increase in social interactions (C10).

Increase in self-determination (C11).

Increased participation in play and/or recreation activities (C12).

Increased participation in community and independent living activities (C13).

Increased participation in age-appropriate transition activities (C14).

Increase in student’s employment and/or post-secondary education experiences (C15)

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* 22. MoDBTAP staff members may require the following supporting documentation. Please check all that are available once a Release of Information has been secured.

IFSP or IEP

Most recent vision report

Triennial Evaluation

Most recent audiological report

Functional vision or hearing reports

For FOCUSED TA requests, this completes the application. For COMPREHENSIVE TA, please complete the verification below.

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* 23. Verification and Documentation (to be completed for Comprehensive TA requests only). The following individuals are in agreement with the technical assistance needs described above.

Family representative is aware of request and in agreement.