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Training/Technical Assistance


and Lending Library Request

Personal Information:

Name

School/Agency

Address

City

State

Zip/Postal code

Phone

Email Address

School District/EIA/SOP:


Title:

Program Affiliation: (check all that apply)

Adult Ed./Family Literacy
Early Childhood Spec. Ed.
Early Intervention
Even Start
General (or Regular) Education
Head Start
Homeless

Migrant Education
Occupational Child Care
Preschool Initiative
School Age Spec. Ed.
Title 1
Other

Content Areas: (select no more than 3)

Assessment
Behavior
Child Find
Classroom Management
Collaboration/Team Building
Communication/Language
Community Based Instruction
Curriculum/Instructional Methods
Disability Characteristics
Feeding/Oral Motor
IEP/IFSP/504
Inclusive Practices
Math
Medical

Motor
Parent/Family
Reading
School Safety
Self-Determination
Sensory
Social Skills
Technology
Transition - Preschool
Transition - Secondary
Transition - Misc.
Vocational/Employment
Writing
Other (Please Describe: )

Service Delivery Method:

Consultation
Information
Library
Training

Disability Descriptions: (check all that apply)

ADD/ADHD
Autism
Blind
Deaf-Blind
Deafness
Developmental Delay
Emotional Disability
Hearing Impairment

 Intellectual Disability 
Learning Disability
Multiple Disabilities
Orthopedic Impairment
Other Health Impairment 
Speech or Language Impairment
Traumatic Brain Injury
Visual Impairment

Service Description: (Include age/grade level
for consultation, list library item no., ex. DSA 017 for Autism Insights)

       


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