Center for Autism and Related Disabilities at USF

Parents with Teen


Request for CARD Technical Assistance
Please fill out the following form completely:

Date of request:	5/13/2008 11:55:47 PM	Phone:	( ) -
School/Agency:		Fax:	( ) -
Contact Person:		Position:
Adminstrator:
Address01:
Address02:
Address03:
City:		State:
Zip Code	+4	E-mail:

	In order to more effectively respond to your technical assistance needs, please complete the following:

	1. We are requesting technical assistance/consultation to improve:



	2. The content area(s) for which we are requesting technical asistance is (are): (Please check all that apply.)

	Supports/strategies to address behavior and classroom behavior management.
	Supports/strategies to increase communication skills.
	Supports/strategies for data collection.
	Supports/strategies to increase social interaction skills.
	Curriculum and instruction
	Teaming and Collaboration
	Transition planning
	Other (Please list)

	3. Describe the desired outcome(s) you hope to achieve from this technical assistance.



	4. Describe your setting. (type of classroom; age of students; number of students; staff-to-student ratio, etc).



	5. List the preferred dates (days of the week and times) when you are available for CARD to provide assistance.



	6. Any other relevant information.