Low Incidence Equipment / Materials Requisition Form
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1SOUTH EAST SELPA
LOW INCIDENCE EQUIPMENT / MATERIALS REQUISITION FORM
(Incomplete forms cannot be processed and will be returned)
Request Date
Requesting District
SELPA Code 4311
Requested by
Phone
Email
Delivery Contact
Phone
Email
LI Received Date
LI Received by
1.Student Name
Attending School
District of Service
Low Incidence Disability:
Hard of Hearing
Deaf
Deaf/Blind
Visually Impaired
Orthopedically Impaired
2.Student Name
Attending School
District of Service
Low Incidence Disability:
Hard of Hearing
Deaf
Deaf/Blind
Visually Impaired
Orthopedically Impaired
3.Student Name
Attending School
District of Service
Low Incidence Disability:
Hard of Hearing
Deaf
Deaf/Blind
Visually Impaired
Orthopedically Impaired
Indicate which of the following resources were consulted prior to completing this request:
Assistive Technology Specialist
Speech/Language Pathologist
CCS
Vision Specialist
Speech / Language Pathologist
Other
ITEM(S) REQUESTED (Include detailed ordering information):
Qty.
Model/Part Number
Description
Cost Each
Total Cost
1.
2.
3.
4.
Attach additional page if necessary for additional student names & Items
Sales Tax $
Shipping $
Total Cost $
VENDOR
Name
Phone
Fax
Address
City, State Zip
Representative
Website
DESCRIBE NEED:
(Please attach report and current IEP that indicate the need for low incidence materials/equipment)
District Administrator Signature
Date
Low Incidence Action
Date ______________ Approved ________ Denied________ Returned for further detail _________
SELPA Director Signature ____________________________________________________________________
After obtaining required district administrator approval, email request and necessary documents to
Questions - Telephone: 408.223.3773 Fax:408.532.9311
Rev. July 1, 2014
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