Determination Of Specialized Formats
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1NIMAS/ICAM FORM #2
DETERMINATION OF SPECIALIZED FORMATS
Student’s First Name:
MI:
Student’s Last Name:
STN:
Date:
Is the student Chafee Qualified? Please Select. . .
Specialized format(s) needed:
Braille
Large print
Audio
Digital text
Other (i.e. DAISY format) (Explain):
This student will also require the use of tactile graphics: Please Select. . .
Specialized formats of instructional materials are needed for use (check all that apply):
at school
at home
other
If other, please explain:
(Please note that only one copy of braille and large print material can be ordered from ICAM.)
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Complete at the end of the first year and following years: Did the use of specialized
instructional materials benefit the student? Please Select. . .
If yes, please indicate how the accessible/specialized instructional materials benefited the student:
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