Frequency (Ex. 1-2x/month) Duration (Ex minutes) Integrated Center Program Separate Center Program Oakland Schools/Havenwyck Program

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1 District Service Request (DSR) School Year: 2016 / 2017 Student Information First Name: Last Name: Date of Birth: Date of IEP / IFSP: Grade: Eligibility: Resident District: Attending District: Attending Building: 504 Plan for HI/VI School of Choice Out of County Contact Information Contact Person: Title / Job Role: Phone Number: Direct Services Direct support for the implementation of IEP goals and objectives for low incidence disabilities Service Type Frequency (Ex. 1-2x/month) 2111 Pontiac Lake Road Waterford, MI Telephone: Facsimile: Duration (Ex minutes) Supplementary Aids / Services Consultation services and materials requested from Oakland Schools Service Type Frequency (Ex. 1-2x/month) Duration (Ex minutes) OR Context Evaluation Participate with local district teams in evaluation activities HI TBI VI O&M Psychiatric (Fee for Service) Consent Date: / / Consideration Process for AT Oakland Schools staff will participate with local district teams in completing the AT Consideration Process Consideration for: Consideration for: Augmentative/Alternative Communication Written Production due to Physical Limitations Placement Facilitate accessing student placement Integrated Center Program Separate Center Program Oakland Schools/Havenwyck Program Problem Solving Facilitate problem solving for students with complex needs Individual Student District Special Education Director Date Oakland Schools Supervisor Date Send DSR and documents to: DSR Fax or through Secure Drop Box to DSRrequests@oakland.k12.mi.us (See checklist for required documents and directions) Oakland Schools Feedback to Local Districts Status Service Type Service Provider(s) Name Comments In Process Incomplete Oakland Schools Department of Special Populations

2 DSR Checklist Items needed to process request Direct Service Direct support for the implementation of IEP goals and objectives for low incidence disabilities MET (if initial or re-determination) Supplementary Aids/Services Consultation services and materials requested from Oakland Schools MET (if initial or re-determination) AT Consideration Process Document (Only for initial requests for AT from OS) Evaluation Participate with local district teams in evaluation activities REED/Consent signed and dated by parent/guardian Medical Reports (i.e. Ophthalmological/ Optometric report or Otolaryngology (ENT), Audiological reports, Medical Documentation of TBI) Psychiatric Fee for Service ($1,000) Current social history, most recent psychological and educational testing and teacher reports Specific areas of concern to be addressed by psychiatrist Incident reports (if applicable) 2111 Pontiac Lake Road Waterford, MI Telephone: Facsimile: Consideration Process for AT Oakland Schools staff participate with local district teams in AT Consideration Process with clearly defined need for expressive communication and or physical limitation which impacts written production Placement Facilitate accessing student placement Placement Packet (available at Problem Solving Facilitate problem solving for students with complex needs Problem Identification Document 504 Plan for HI/VI Current 504 Plan If HI, Medical clearance for amplification provided by ENT Physician completed within last 12 months If HI, Student uses personal amplification compatible with OS Hearing Assistive Technology Oakland Schools Department of Special Populations

3 Student Name: District Date: Student Problem Solving Problem Identification Document To assist us in determining your team s needs for this student, please provide the following information. You may expand spaces to accommodate your needs. Define the presenting problem(s) in observable and measurable terms (i.e., frequency, duration, intensity). Provide a focused synopsis of interventions including length of time used, data and results (positive and negative). What outcome would you like to see for this student? Anything else that we should know?

4 The Oakland Schools Secure Drop Box WELCOME TO THE OAKLAND SCHOOLS SECURE DROP BOX The Oakland Schools Secure Drop Box is a secure method for transferring sensitive messages. Access the site at: CREATE AN ACCOUNT Click Click Here Enter address Note: OS Technical campus employees must enter OSLAN id, not address. Click Next Note: You will receive the following message if an account already exists: Your address already has been added and is ready for use. Please login. Complete My Settings USERS WITH AN OAKLAND SCHOOLS ADDRESS: Enter First Name Enter Last Name Enter Organization Enter Phone Number Enter OSLAN ID Optional: Enter Signature Enter Security Code displayed in the box to the right Read Terms of Use Check I Agree Click Create Account Note: Fields with * are required. Welcome, you may now login using your OSLAN account information. USERS WITHOUT AN OAKLAND SCHOOLS ADDRESS: Enter First Name Enter Last Name Enter Organization Enter Phone Number Enter Address Optional: Enter Signature Enter Password information Enter Security Code displayed in the box to the right Read Terms of Use Check I Agree Click Create Account Note: Fields with * are required. To complete the new account process, please click the LINK in the that you will receive. This account was added. An has been sent to you with a link that will complete this New Account process.

5 COMPOSE AND RECEIVE FILES LOGIN THE OAKLAND SCHOOLS SECURE DROP BOX MAIN MENU COMPOSE a message to send or save as a draft. Enter address and Password Reminder: Oakland Schools employees should use their network password. Note: Password is case-sensitive. Click Login Options: Click Forgot Password? to obtain a new password. Check Change my password after Login. to change your password. Enter Address of Recipient(s) Enter Subject Enter Message Click Send Message or Save as Draft Options: Click Check Names to determine whether the recipient exists on the white list. If not, request that they be added. Click to invoke the spell checker. Click Select to add an attachment. Check Read Receipt is required to receive an when the recipient has read the message. View your INBOX folder to reply, forward or delete messages. View, send or save messages that have been saved as DRAFT. View, reply, forward or delete messages in your SENT folder. View, reply, forward or delete messages in your DELETED folder. View and edit personal and security information in MY SETTINGS. TO RECEIVE SECURE DROP BOX MESSAGES Login to your account and click the LINK that is referenced in an message. A NOTE about MESSAGE RETENTION: Messages will automatically expire after 168 hours (approx. 7 days) For more information, please contact the Oakland Schools Helpdesk: Phone: helpdesk@oakland.k12.mi.us Online ticket submission: