Georgia Bureau for Students with
Physical & Health Impairments
ON-SITE TA Request Form
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Georgia Bureau for Students with
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General Information
Teacher: ______________________ School System: ____________________
Student(s):_____________________ School:___________________________
Name of Special Education Director: ________________________________________
Person requesting technical assistance: _______________________________________
Phone: ________________________ E-mail: ___________________________
Target Areas
Describe areas that you want addressed during the on-site visit:
Permissions (Required for school on-site visits)
____________________ The principal was consulted and gives permission for the
(Principal signature) Bureau for Students with Physical & Health Impairments to
provide on-site technical assistance.
____________________ The Special Education Director was consulted and gives
(Signature of person who permission for the Bureau staff to provide on-site
talked with Director) technical assistance.
________________________________________________________________________
Please return this form to:
Dr. Kathryn Heller/ Ms. Mari Beth Coleman-Martin
Georgia Bureau for Students with Physical & Health Impairments
Fax: (404) 651-4901
E-mail: physicaldisabilities@gsu.edu or kheller@gsu.edu
Mail: Dr. Kathryn Heller/ Mari Beth Coleman-Martin
Dept. EPSE
Georgia State University
PO Box 3979
Atlanta, GA 30302- 3979