Eligibility And Certification For Specialized Formats Of Print Instructional Materials Form printable pdf download

ELIGIBILITY AND CERTIFICATION FOR SPECIALIZED FORMATS OF PRINT

INSTRUCTIONAL MATERIALS

The Individuals with Disabilities Education Improvement Act (IDEIA) 2004 includes a definition of students

who may be provided with accessible textbooks created with NIMAS-conformant files from the National

Instructional Materials Accessible Center (NIMAC). That definition, used within the legislation, is "blind or

other persons with print disabilities." "Blind or other persons with print disabilities" means children served

under IDEA who may qualify in accordance with the act entitled, "An Act to provide books for the adult blind,"

approved March 31, 1931 (2 U.S.C. 135a; 46 Stat. 1487) to receive books and other publications produced in

specialized formats [674(e)(3)(A)].

In order to qualify to receive K-12 textbooks and core instructional materials in specialized formats, rendered

from NIMAS files, the student must have: (1) an Individualized Educational Plan (IEP); and (2) a certification

of a print disability, by a recognized competent authority, on file with school district. A competent authority is

defined to include doctors of medicine, doctors of osteopathy, opthalmologists, optometrists, registered nurses,

therapists, professional staff of hospitals, institutions, and public or welfare agencies (e.g. social workers,

counselors, rehabilitation teachers and superintendents).

In the case of a reading disability from organic dysfunction, competent authority is defined as doctors of

medicine or osteopathy who may consult with colleagues in associated disciplines.

In order to receive specialized formats of K-12 print instructional materials derived from NIMAS

conformant files, the rest of this from must be completed by a competent authority as listed.

TO BE COMPLETED BY CERTIFYING AUTHORITY:

I certify that the student named below is unable to read or use standard printed materials for the

reasons(s) indicated below:

BLINDNESS

Visual acuity of 20/200 or less in the better eye with correcting glasses, or the

_____

widest diameter of visual field subtending an angular distance no greater than 20

degrees.

_____ VISUAL DISABILITY

Inability to read standard printed material without aids or devices other than

regular glasses.

_____ PHYSICAL DISABILITY

Inability to read or use standard printed material due to physical limitations.

_____ READING DISABILITY

Organic dysfunction of sufficient severity as to prevent reading standard print

material in a normal manner

STUDENT NAME (Please Print) ______________________________________________________________________________

CERTIFYING AUTHORITY TITLE ________________________________________________ DATE ____________________

BUSINESS/ORGANIZATION NAME _________________________________________________________________________

ADDRESS ________________________________________ CITY __________________________________________________

STATE __________ ZIP CODE _______- ____________ PHONE (Office) _____________________ (Mobile) _______________

Signature of Certifying Authority ____________________________________________________________

(

Original signature required - not a signature stamp; faxes or copies of the certification are not acceptable)

Eligibility And Certification For Specialized Formats Of Print Instructional Materials Form