Request for Changes Form

The University of Iowa
Regional Autism Services Program
Child Health Specialty Clinic

Request for Changes Form

Graphic Supplement Packet
for Autism Resource Team Members and
District and AEA Instructional and Related Services Staff

Please check the modifications that apply:
	Gender of child	Age of child
	girl	Preschool
	boy	Elementary
		Junior High/High School

Please give a description of any of the following changes that are needed:

Action of the child in the graphic:

Object(s) in the picture:

Words describing the graphic or an action:

Miscellaneous changes or suggestions for new graphics: