Assistive Technology Repair Replacement Form



Assistive TechnologyRepair or replacement formThis form is used to apply for funding to repair or replace Ministry of Education funded Assistive Technology when the total is over $100.Replacements need to be essentially the same as the current equipment. Upgrades or changes in technology require a full application. Warranty: contact the supplier if the equipment is still under warranty for repair / replacement (do not use this form). Refer to the Insurance and Repairs fact sheet for more information: t.nzPlease download and SAVE this form before use. This form is specifically formatted for use in Microsoft Word and will lose some functions if used with other programmes (e.g. Google Docs).To complete this form you will need:?Current quotes for repair or replacement of technology (if a repair is not viable, include a cost effective quote for a like-for-like replacement)?Repair assessment (required if replacement or extensive repair is being requested)?Copy of school’s insurance information, detailing insurance excess amount if the repair or replacement is due to damage or loss01Student information Student’s name: (first) (last) Date of application: Date of birth: Age: School year level: School name: School email: Learning Support Coordinator/SENCo: Email: Person completing this form: Name: Role: Telephone: Email: Month and year this equipment was allocated to this student: Eligibility criteria used for original application:? ORS – Very High ? ORS – High ? Physical Disability Service ? Services for Deaf and Hard of Hearing? Services for Blind and Low Vision? Behaviour Services and Support ? Speech Language (Communication) Service ? School High Health Needs Fund (SHHNF) ? In Class Support (ICS) ? Resource Teacher Learning and Behaviour (RTLB)? Special Education Grant (SEG)? Other additional learning support? I confirm that this student’s learning needs cannot be met by the equipment available to them in the school. ? I confirm funding responsibility lies with the Ministry of Education, under the protocols between Education, Health and ACC.Do you expect this student to move to another school/leave school within the next 6 months? ? Yes ? No If yes, please provide the following details: Name of new school: Has the use of this technology been discussed with the new school? ? Yes ? NoDescribe the relevant technology available to the student in the new school, including BYOD if applicable): 02Current technologyNB. Contact your local AT coordinator for list of equipment ID numbers if not knownAssistive technology details (with serial numbers as appropriate)Ministry of Education equipment ID number Record dates and details of previous repairs or other issues related to this equipment (if known): Describe how the student uses this assistive technology to support their learning: Why does the above listed item(s) need to be repaired or replaced? 03Cost of repair or replacement technologySupplier name and invoice number (if supplied)Technology details (list and price each item separately) Cost(excl. GST)GST calculatorTOTAL(incl. GST)Total cost of repair/replacementIf this repair/replacement is due to loss or damage, write the school’s insurance excess here: $The Ministry of Education will cover the lower of:total cost of replacement/ repair OR (b) cost of the school insurance excess Amount requested04Management plan ? Detailed management plan is attached (recommended in cases of loss or damage)The assistive technology will be monitored and maintained by (please tick):? School IT support? Supplier ? Not applicable? Other (please describe): When the assistive technology is not being used it will be (please tick):? Placed on the teacher’s desk? Locked in a classroom cupboard? Not applicable? Other (please describe): This assistive technology may go (please tick):? Home each day to complete essential homework tasks? Home during the school holidays to consolidate learning ? Does not go home? Other (please describe): Other management: 05Acceptance of responsibility - principal to completePlease note the following processes and conditions must be followed if the application is successful. You accept that the school:Will order and pay for the assistive technology using the quote from this application, where applicable.Will take ownership of the assistive technology for the time that the student is enrolled in the school. This includes listing the technology on the school’s asset register, maintaining a record of the serial numbers along with supplier details and warranty conditions.Is responsible for insuring and maintaining the assistive technology and will contact the local Ministry of Education office if costly repairs, maintenance or replacement of the item is needed.Is responsible for the safekeeping of all assistive technology items such as original software, account ID and passwords, manuals and accessories etc. as documented in the management plan.Will load appropriate school software and use appropriate school technology to support the student, such as generic programs like Microsoft Office, virus software and access to school networks and systems.Will support the ongoing use of the assistive technology and ensure it is used for the intended purpose by the student it is allocated for.Will contact the local Ministry of Education office when this student transfers to another school or leaves school, and will transfer the assistive technology to the new school or return it to the Ministry of Education.Agrees that the electronic version of this document can act as the record copy for this application.Principal name: School: Signed (Principal): Date: Principal email: 06Checklist? Attach current quote for replacement or repair of technologyIn cases of loss or damage, include: ? School’s insurance information detailing insurance excess? Repair assessment? Copy of original or revised technology management planPlease email the completed application form, with all required attachments as a single PDF to the assistive technology coordinator at your local Ministry of Education office. The Ministry will manage all personal information collected from this form in accordance with the provisions of the Privacy Act 2020.Applications are due by the first Tuesday of each month (Feb – Nov) for consideration that month. Urgent applications may be considered on a case by case basis so please contact us if you have special circumstances.Optional page for inserting quote or insurance info ................
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