Low Vision Reimbursement Program Claim
CALIFORNIA DEPARTMENT OF EDUCATION
Curriculum Frameworks and Instructional Resources Division
Clearinghouse for Specialized Media and Technology
1430 N Street, Suite 3207, Sacramento, CA 95814
Telephone (916) 445-5103; FAX (916) 323-9732
LOW VISION REIMBURSEMENT PROGRAM CLAIM
SELPA: ________________________________ CONTACT: ___________________________
ADDRESS: _____________________________ CITY, STATE, ZIP: _____________________
PHONE: ______________________ FAX: ___________________ e-mail: ________________
During the fiscal year __________, programs for the visually impaired served _____ students.
A total of ____________ large print instructional materials were purchased at a total cost of $___________________. A total of ____________ video magnifiers were purchased at a total cost of $___________________. A total of ____________ nonprescription optical aids were purchased at a total cost of $___________________.
Attached, as appropriate, are copies of all paid invoices, purchase orders, stock received reports, Large Print Vendor Responsibilities form, and evidence of posting on the Braille-N-Teach list service. All documents, excluding the claim form, contain the following information: title of the book, ISBN number, and the cost of each item being purchased from the vendor.
Large print book titles adopted by State Board of Education (kindergarten through grade 8 only) that are no longer needed will be delivered to: California Department of Education, CSMT Media Warehouse, 3740 Seaport Blvd., #20, West Sacramento, CA 95691.
Video magnifiers and nonprescription optical aids that are no longer needed in the SELPA will be shared with adjoining SELPAS, or posted on the CDE’s Braille-N-Teach list service as being available at no cost to other programs.
The SELPA will dispose of broken or obsolete equipment in accordance with local district policy in compliance with the California Education Code sections 17545-17555.
I certify that all information provided is true and correct to the best of my knowledge. I further certify to the following:
- That books produced in large print have been adopted by the local governing board.
- That the Price List of Adopted Instructional Materials has been searched or that the publisher has been contacted to determine the availability of suitable alternate formats.
- That queries have been made through the CSMT’s Instructional Materials Ordering and Distribution System and the Louis Database of Accessible Media (Outside Source) to determine the availability of needed material or equipment.
- That other professionals have been consulted or that assessments have been made to determine the best resources for the student.
SELPA Director: ___________ ________________________________
CDS (County-District-School) code _______________________ Phone: _____________________
Signature: ___________________________________________________ Date: ____________
*E-mail: Steve Yee at syee@cde.ca.gov to subscribe to the CDE’s Braille-N-Teach listserv.
**SELPAs are required to advertise on the Braille-N-Teach listserv that the books are no longer needed and are available to other programs through the CSMT.
