Basic Information
Contact information
Request Information

*Please provide a copy of both the ETR and IEP on the day of the DBTAP observation.

Please click on all individuals who have been informed of the Request for DBTAP Consultation and if the individual will be present for the onsite DBTAP consultation.

Related Services That the Child Is Currently Receiving

Please click on all the services that apply and provide name and email of provider of the service.

What is the Preferable Location and Time of Day for the DBTAP Observation?
Information About the Child/Student
Level of hearing loss (without hearing aids or cochlear implant):

Left Ear
Right Ear
What sounds does the child/student respond to most frequently? (Please specify sounds for each environment):
Does the child/student use assistive technology for hearing? (Please specify):
Level of vision loss (with correction):

Left Eye
Right Eye
Does the child use assistive technology for vision? (Please specify):
Expressive Communication modes used by the child/student to express himself/herself. Please click on all that apply:
Specify all assistive technology the child/student uses to express him/herself:
Receptive Communication modes by individuals to communicate with the child/student. Please click on all that apply:
Orientation and Mobility. (Please click on all that are used by the child):
Self-Help Skills:
Specify all personal equipment currently used with the child/student in:
Additional Information Not Addressed in the DBTAP Request Form:

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