Special Consideration Factor: Need For Accessible Formats Of Print Instructional Materials

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NIMAS/ICAM FORM #1
Special Consideration Factor: Need for Accessible Formats of Print Instructional Materials
Student’s First Name:
MI:
Student’s Last Name:
STN:
Date:
Decision Makers: Case Conference Committee Members
The IEP team has considered whether or not the student requires specialized formats of standard print material.
Consideration should include the following:
Student receives special education services as a student with a visual impairment and requires specialized formats
to access the curriculum.
Yes
No
If yes, there must be certification on file, by a competent authority (see definitions page), documenting that
the student has a visual disability (see definitions page) that prevents him from reading standard print
materials.
OR
Student receives special education services as a student with a physical limitation that impairs his/her ability to
access standard print material and requires specialized formats to access the curriculum.
Yes
No
If yes, there must be certification on file, by a competent authority (see definitions page), documenting that
the student has a physical disability that prevents him from reading or using standard print materials.
OR
Student receives special education services as a student with a reading disability resulting from organic
dysfunction and of sufficient severity to prevent reading standard print material in a normal manner. The student
requires specialized formats to access the curriculum.
Yes
No
If yes, there must be certification, from a competent authority (see definitions page) on file documenting
that the student has an organic dysfunction that prevents him from reading standard print.
CHECK ONE:
Student is Chafee qualified and is eligible to receive formats from the NIMAC/ICAM (Check if the answer to any of the
above is ‘Yes’).
If checked, complete FORM #2: DETERMINATION OF SPECIALIED FORMATS, FORM #3- A: ICAM ADD/UPDATE
STUDENT DATA, and #3-B: ICAM REQUEST FORM.
Student is not eligible for Chafee qualified services but the Case Conference Committee has determined the student
requires specialized formats of instructional materials.
If checked, complete FORM #2: DETERMINATION OF SPECIALIZED FORMATS and FORM #3-A: ICAM
ADD/UPDATE STUDENT DATA and #3-B: ICAM REQUEST FORM.
Case Conference Committee has determined that Student does not require specialized formats of instructional materials.

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