Connections Beyond Sight and Sound title

Information and Referral Form for Technical Assistance

To request technical assistance from the Connections Staff, please complete the form below. Please note: You will need to have your browser configured to send e-mail in order to complete this form. If you are unable to complete the form or need further information, please e-mail Diane Kelly at dmkelly@umd.edu

Person Requesting Assistance:

Role/Organization:

Address:

Phone:

Fax:

E-mail:

How did you find out about us?

	website
	attendance at a CBSS-sponsored activity
	newsletter
	teacher referral
	parent referral
	other

Student Information

Student Name:
Date of Birth:

Please Provide a Brief Description of the Child:

School:
School System:
Principal:
Contact Person:
Phone:

What do you need?

	Consultation
	Materials
	Training
	Site Visit
	Referral
	Information
	Other (please explain):

Content Area:

	Assessment
	Behavior Support
	Curriculum/IEP Development
	Instructional Strategies/Adaptation
	Augmentative Communication
	Transition
	Inclusion
	Support Groups/Equipment
	Other (please explain):

Office of Special Education Programs logo

Department of Special Education
University of Maryland
1308 Benjamin Building
College Park, Maryland 20742

This Project is supported by grant # H326C99053 from the
U.S. Department of Education and Part B funds

Diane M. Kelly, Ph.D.
Project Director
Donna J. Riccobono
Project Coordinator


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