Form DWS-USOR UCAT01 "Assistive Techonology (At) Referral Form" - Utah

What Is Form DWS-USOR UCAT01?

This is a legal form that was released by the Utah Department of Workforce Services - a government authority operating within Utah. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on January 1, 2019;
  • The latest edition provided by the Utah Department of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DWS-USOR UCAT01 by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-USOR UCAT01 "Assistive Techonology (At) Referral Form" - Utah

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DWS-USOR UCAT01
State of Utah
Rev. 01/2019
Department of Workforce Services
ASSISTIVE TECHONOLOGY (AT) REFERRAL FORM
Complete as much information as possible and email to
ucat@utah.gov
or fax to 801.974.5477
TYPE OR WRITE LEGIBLY
Date of Referral:
I.(a) Client Contact Information
Name:
Phone:
Street Address:
Apt #:
City:
State:
Zip Code:
Email:
I.(b) Demographic Information
Ethnicity:
American Indian and Alaska Native
Asian
Black or African American
Does not wish to self-identify
Hispanic or Latino
Information not available
Native Hawaiian or Other Pacific Islander
White
Date of Birth:
Gender:
Male
Female
Does not self-identify
Not available
I.(c) Disability(ies) (Cause if available):
I.(d) Contact Person (Other than client):
Phone:
Relationship to Client (Mark one):
Parent
Spouse
Child
Caregiver
Other (Specify):
II. Type of AT Service Requested: (Mark ALL that apply)
Transportation
Job- and/or home-site assessment
Activities of Daily Living
Augmentative Communication
Vehicle Hand Controls
Educational Assistance Technology
For services below only:
Height (in)
Weight (lb)
Alternative Computer Access
Wheeled Mobility
Computer System Recommendation
Other Mobility
PC Loan (VR clients only)
Seating & Positioning
Other (Specify):
III. Purpose of Referral (Be specific; include functional limitations and vocational or independent-
living goals):
DWS-USOR UCAT01
State of Utah
Rev. 01/2019
Department of Workforce Services
ASSISTIVE TECHONOLOGY (AT) REFERRAL FORM
Complete as much information as possible and email to
ucat@utah.gov
or fax to 801.974.5477
TYPE OR WRITE LEGIBLY
Date of Referral:
I.(a) Client Contact Information
Name:
Phone:
Street Address:
Apt #:
City:
State:
Zip Code:
Email:
I.(b) Demographic Information
Ethnicity:
American Indian and Alaska Native
Asian
Black or African American
Does not wish to self-identify
Hispanic or Latino
Information not available
Native Hawaiian or Other Pacific Islander
White
Date of Birth:
Gender:
Male
Female
Does not self-identify
Not available
I.(c) Disability(ies) (Cause if available):
I.(d) Contact Person (Other than client):
Phone:
Relationship to Client (Mark one):
Parent
Spouse
Child
Caregiver
Other (Specify):
II. Type of AT Service Requested: (Mark ALL that apply)
Transportation
Job- and/or home-site assessment
Activities of Daily Living
Augmentative Communication
Vehicle Hand Controls
Educational Assistance Technology
For services below only:
Height (in)
Weight (lb)
Alternative Computer Access
Wheeled Mobility
Computer System Recommendation
Other Mobility
PC Loan (VR clients only)
Seating & Positioning
Other (Specify):
III. Purpose of Referral (Be specific; include functional limitations and vocational or independent-
living goals):
IV. Other Information That Could Be Helpful to the AT Assessment Process:
V. Referring Agent Contact Information:
Name:
Email:
Phone:
Agency:
Office:
Other Agency Involvement (if known):
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162.
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