Iowa Education Services for the Blind and Visually Impaired
Site of Sense (Active Learning)Equipment Checkout Form
2015-2016 Year
Student Name:
TVI/OMS Name:
LEA Contact & School District:
Date of Request:
Student goal for equipment being checked out:
Equipment requested: (TVI/OMS indicate equipment wanted)
_____Site of sense room similar to little room
_____wheel chair riserallows kids to access sight of sense room while in their wheelchair
_____vibration base similar to resonance board
_____ wall of sense *thisneeds to be mounted on a wall
Model & serial number of equipment sent(Pat Barr to fill out):
Date sent:
Who transported:
Post-Checkout Information:: (TVI/OMS to fill out)
Will equipment be purchased as a result of the assessment conducted with trialed equipment?
If yes, what equipment is being purchased?
Other Comments:
Policy and Procedure:
- Check out period is 3 months for assessment purposes.
- Sample data collection sheets are available for each piece of equipment.
2. If circumstances require checkout longer than 3 months, please contact Pat Barr.
*Timely return of equipment is appreciated, in the event there is a waiting list.
3.Requests for checkout of equipment will not be filled if a checkout form is not received by Pat Barr.
4. If you are planning to use equipment for more than one student, a checkout form should be sent when the transfer of equipment is made. Approval for this checkout is required by Pat Barr based on requests by other TVIs and waiting lists for equipment.
5. Video instructions for set up (sorry these are a bit rough – hoping to re-record):
- Part 3 (2.47 minutes) Putting the site of sense room together
- Part 4 (50 sec) How to use plugs to hang equipment
- Part 7 (1.34 min) putting the site of sense on the wheel chair riser
6. Please, try not to request equipment if you know assessment/use cannot start promptly.
7. After trial of equipment for assessment purposes, the Local Education Agency is responsible for ordering and purchasing the equipment.
8. The Local Education Agency is responsible for the cost of maintenance and repair of LEA purchased assistive technology.
Send completed EquipmentCheckoutform to:Pat Barr
319-472-5221 ext 1110 / Other questions, comments or support:
Cynthia White-Botello
Consultant for Children with Multiple & Visual Impairments
319-310-1322
Iowa Education Services for the Blind and Visually Impaired
Site of Sense (Active Learning)Equipment Checkout Form
Resources:
1. More information on “Site of Sense” equipment can be found at
2. Data Collection forms can be found at the IESBVI website and will be included
3. On-line resources related to active learning, also called space for active learning can be found at:
- “An Introduction to Active Learning” this is a brief article on active learning that might be nice to hand to teachers/parents/teams when they receive the equipment.
- “Why do we need a Space for Active Learning?” this is a webpage with a brief explanation of active learning that includes short video exemplars.
- “Active Learning for Children and Youth with Visual and Multiple Impairments” a longer on-line training series by the Washington Sensory Disabilities Services Site
- “Active Learning and Lilli Works” on Youtube includes the parents perspective and some nice examples of children in active learning environments
Optional Signature Documentation
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______
I have read and understand the above conditions for checkout of equipment from Iowa Education Services for the Blind and Visually Impaired.
Signature: ______
Position: ______
Date: ______