Skip to content

DeafBlind Technical Assistance* Request

* TA is a process of providing targeted support

Missouri DeafBlind Technical Assistance Project (MoDBTAP) provides two types of TA: focused and comprehensive. A description of each is provided below.

Focused TA
Focused TA is delivered at a targeted/specific level and is based on the clearly-identified needs of family members, program/school staff, and/or administrators. Focused TA is short-term assistance designed to address a basic, single need or a small number of basic needs, and is delivered via distance technology. This level of TA emphasizes the efficacy of family/ professional partnerships in supporting child change.
Comprehensive TA*
Comprehensive TA is delivered at an intensive/sustained level and requires a stable, ongoing relationship between MoDBTAP staff and TA recipients. Comprehensive TA can be delivered onsite and/or through distance technology. It includes a purposeful, planned series of activities designed to reach outcomes that are valued by the individual recipients. Family members, program/school staff, and administrators identify and agree to a set of TA needs to be addressed as part of the TA process. This level of TA should result in changes to practices and/or operations that support increased recipient capacity and/or improved outcomes .

*Adapted from the U.S. Department of Education, Office of Special Education Program’s definition of intensive/sustained technical assistance.
1.Type of technical assistance requested
2.Information about person completing this referral:
3.Is the person completing this referral the primary contact for MoDBTAP staff? If not, please provide the following information for the primary contact:
4.Information about the child/student:
5.Information about the school the child attends if the child is school age:
6.What is the etiology related to the student's deafblindness (CHARGE, Ushers, etc)?
7.Is the child receiving Occupational, Physical, Speech or other therapies?
INFORMATION ABOUT CHILD'S VISION
8.Does the child have functional vision? If so, describe what you think the child can see. (Attach a recent eye report or functional vision assessment if available.)
9.Eye Report/Functional Vision Evaluation/Eye information
No file chosen
10.Does the child wear glasses/contacts and/or use any assistive technology related to vision? ie magnifiers, speech output, CCTV, uses a white cane for travel?
INFORMATION ABOUT CHILD'S HEARING
11.What is the auditory condition, diagnosis, or etiology?
12.Does the child have functional hearing? If so, describe what you think the child can hear. (Attach a recent audiogram or functional hearing screening below if available.)
13.Does the child wear hearing aids? Cochlear implant? Other assistive listening devices?
14.Audiological reports/hearing assessments, medical reports on hearing
No file chosen
15.Describe the child’s expressive and receptive communication mode(s). These might include speech, American Sign Language (ASL), signed communication (i.e., single signs or signs used in English word order), voice output devices or tablets, symbols, objects, etc.
16.Does the child effectively communicate wants? Needs? Emotions?
17.What is the primary language used by others in the home?
18.Describe the child’s gross and fine motor abilities (e.g., walking, standing, crawling, grasping, etc.). Does the child use any adaptive equipment/devices to perform everyday activities?
19.Is there any additional information about the child that would be important for MoDBTAP staff to know?
AREA OF FOCUS-Check the top THREE areas that are priorities of the team at this time
20.Top THREE areas of concern at this time
RESULT OF TECHNICAL ASSISTANCE. As a result of this technical assistnace, what would you like to see occur for the child. Select the top THREE areas.
21.Top THREE areas that you would like to see occur from the technical assistance related to the top three areas of concerned indicated above.
22.MoDBTAP staff members may require the following supporting documentation. Please check all that are available once a Release of Information has been secured.
For FOCUSED TA requests, this completes the application. For COMPREHENSIVE TA, please complete the verification below.
23.Verification and Documentation (to be completed for Comprehensive TA requests only). The following individuals are in agreement with the technical assistance needs described above.