RSSForm - CESA 9

CESA #9 Regional Support Systems Project - Service Request Form:

District:

District Address:

Contact Person: (This is the individual who will be able to make all necessary local district arrangements (i.e meeting place and time, schedules, etc.)

Date:

Phone #:

Fax #:

Purchase Order #:

Specific Service Request Details: (Be brief and to the point - what question, topic or issue needs to be addressed?)

Approximate amount of support time anticipated: (This should be based on the best estimate of total time, including student contact, staff consultation, IEP meeting time, etc.)

10.

When is this service needed? (Indicate the time frame within which this support service is needed, especially where there are IEP timeline restrictions).

Project Goals:

Develop a system of support for school personnel tailored to the needs of individual children with special education needs.
Maintain an ongoing system of support for school personnel tailored to the needs of children with special education needs.

Basic tenets of this project:

Service is available to all districts.
Service requests MUST be accompanied by a Purchase Order.
Requests may be made by mail, fax or phone.
It is the responsibility of the district receiving service to arrange local schedules.
CESA #9 will share the VITA of the resource person with the local district upon request.
CESA #9 will provide support to resource persons who are contracted for service delivery.
A written report will follow each service delivery (or sequence of deliveries on the same request) within a reasonable time.
It is the responsibility of the service provider to prepare a written report within a reasonable time.
CESA #9 will attempt to respond promptly to each request, but cannot assure a resource is available, at the time, for every request.

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