Assistive Technology Equipment Panel Referral Form

Please refer to the ATEP guidance notes when completing this form. Any incomplete forms will be returned to you to complete and re-submit. Your request will be considered by the ATEP panel at set intervals, to ensure it is appropriate. By submitting this form you are agreeing to the following:

The education setting is responsible for collecting from or returning the equipment to the Old Railway School, Ashford. Prior notice must be given before arrival for any returns or collections.

The education setting will be responsible for setting up equipment. If equipment is required to be added to the IT network, E-Safety policies are to be followed.

The education setting will ensure the equipment is recorded on their insurance and understand they are responsible for the loss or damage of equipment on their premises.

The equipment is PAT tested annually by the education setting.

Any repairs or faults required are reported back and they must arranged through the ATEP fault process.

The equipment is on long term loan to the student and should transition with them if education setting changes. In this instance, the education setting must inform ATEP.

The equipment is available for the student to use as intended and should be evaluated 1 year after issue, should the referral be accepted.

This form should be completed electronically and either printed and posted to the address (below) or emailed through password protected, to the ATEP inbox.

Student Name:	Referrer Name:
Student Address:	Education setting address:
Postcode:	Postcode:
DoB:	Role:
Age:	Phone:
KCC UPN:	Email:

Please include relevant reports from the list below that have issued to the student:	Please include the names of all professionals who were consulted or contributed to the referral:
EHCP:	Date:	Name of specialist staff consulted:
Personalised Plan:	Date:	Name of SLT:
Last 2 review meeting details:	Date 1:	Name of OT:
Date 2:	Other:	Role:

Please outline any difficulties this student experiences accessing the curriculum and how assistive technology could support these difficulties:
(Red font should be removed upon completion, these are just points to consider it help you with completing the form) Please state any outcomes on the student’s plan Access to information, for example written and auditory Access to the white board Barriers to learning
Please summarise the student’s attainment in the last 2 years:
3. Please give details of external specialist advice sought in relation to the use of technology to support the above need. Please attach any specialist assessments relating to use of assistive technology.
4. Please give details of what assistive technology has been used as part of an individual programme over and above normal classroom access to address the student’s special educational needs.
(Red font should be removed upon completion, these are just points to consider it help you with completing the form) What equipment has been used or trialled to support the student so far. Please include low tech, high tech, software, hardware. Please state how frequently and what it was used for.
5. Please indicate low tech communication aids and strategies that have been implemented and evaluated outcomes.
6. Please provide all the details of the equipment you are requesting and that you feel would meet the needs of the student. Please enclose suppliers’ details and a copy of the quotation.
7. What outcome would you expect to see for the student using this equipment, should it be issued

Please ensure that you have read and understood the guidance information and that you are aware of your responsibility and commitment to this process. By submitting this form you are agreeing to the terms set out in the information provided.

Please return the form to:

ATEP

The Old Railway

Wainwright Place

Newtown

Ashford

Kent

TN24 0PF

Email: ATEP@kent.gov.uk

Phone: 01233 629859

If you are emailing the form please be aware of data protection and information governance policies concerning sharing sensitive information.