Blumberg Center for
Interdisciplinary Studies in Special Education

indiana deafblind services project

technical assistance request form

THIS FORM IS CURRENTLY UNDER DEVELOPMENT. PLEASE SEND AN EMAIL TO DB@INDSTATE.EDU IF YOU REQUIRE TECHNICAL ASSISTANCE. WE APOLOGIZE FOR ANY INCONVENIENCE.

If you would like technical assistance services for your Indiana child/student who is deafblind (has both a vision and hearing loss), please complete and return the request form to the Indiana Deafblind Services Project. Once this information is received, you will be contacted by Project Staff to follow-up on your request.

Please provide the following contact information:

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip Code
Work Phone
Home Phone
E-mail
Name of Child/Student
Relationship to Child


What type of technical assistance are you interested in receiving?

Home Visit   

School Visit  
Case Conference
Inservice Training
Resource Materials  
Phone Call   
Email  
Other (specify)
What are the best times to contact you?   AM/PM

Topics of Interest
(Please put a check next to the topic(s) of interest.)

1. Academic Standards
2. Assessment
3. Behavior
4. Causes of Deafblindness
5. Communication
6. Early Intervention
7. Identification of Students who are Deafblind
8. IEP Development
9. Instructional Strategies
10. Person Centered Planning
11. Recreation/Leisure Activities
12. Transition
13. Other Topic
          (Specify the topic:)
          

You may submit this form now over the Internet by clicking the "submit" button or complete this form, print it and return to:

Indiana Deafblind Services Project
Blumberg Center
College of Education
University Hall 009W
401 North 7th Street
Indiana State University
Terre Haute, IN 47809
Fax: 812-237-8089


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