ASSISTIVE TECHNOLOGY
Screening Process & Evaluation Process
TO REQUEST A STUDENT SCREENING
Student Screeningformsshould be completed by referring teacher or therapist and sent to AT Center. Our staff will conduct the student screening and provide findings to the referring teacher.
This includes the following forms:
- Student referral and information forms
- Any of the disability-specific skills checklists that apply to the student’s skills and/or limitations
TO REQUEST A FULL A.T. EVALUATION
Evaluation Referral formsshould be completed by the referring teacher and/or therapist and sent to the AT Center.
This includes the following forms:
- Signed parent consent
- Student information forms
- Any of the disability-specific checklists that apply to the student’s skills and/or limitations
Completed forms should be faxed to the Assistive Technology Center before a screening or assessment can be completed.
Fax forms to:
Janice Reese
Fax: (865) 458-8626
**AT team members from the referring school are expected to participate with assessment. A written report following the evaluationwill be sent to the school system. Requisitions will be sent to central office for purchase of any suggested items. Recommended assistive technologies or strategies will be amended into the IEP as indicated.
Revised 08-29-12
Parent Consent for Assistive Technology Evaluation
Parent/Guardian
On (date), (child’s full name) was referred for a comprehensive assessment for determination of eligibility and need of special education services. This referral is based upon a review of current classroom performance, past educational records, and/or screening information. We are requesting permission to assess your child in order to provide additional information to help us plan a more effective educational program. Also, as the parent of a child who may be eligible for special education, the Rights of children with Disabilities and Parent Responsibility is being provided for your information.
The reason(s) to request your permission to assess you child is (are):
( ) child is working ( ) above grade level or ( ) below grade level in one or more basic skills
( ) child’s behavior is inconsistent with that expected for children of students’ age
( ) child’s rate of progress has ( ) increased ( ) decreased
( ) child’s speech/language skills are inconsistent with those expected for children of student’s age
The areas/procedures to be considered for your child’s assessment are checked below. The extent of the assessment will depend upon the severity of the problem.
____ 1. Vision/Hearing Screening / ____ 9. Audiology Evaluation____ 2. Classroom Observation / ____ 10. Functional Vision Assessment
____ 3. Academic Achievement / ____ 11. Personality Assessment
____ 4. Intellectual Functioning / ____ 12. Vocational Assessment
____ 5. Speech/Language Skills / X 13. Assistive Technology Assessment
____ 6. Gross/Fine Motor Skills / ____ 14. Self Help/Adaptive Behavior
____ 7. Visual/Auditory Skills / ____ 15. Functional Behavior Assessment
____ 8. School and/or Home Behaviors / ____ 16. Other ______
Please sign this form and return it to the school. Your signature shall not be construed as consent for placement in any special education program. When the assessment has been completed, you will be invited to an IEP team meeting in order to discuss the findings, determine your child’s eligibility for special education services and, if needed, plan an appropriate educational program for your child. If you have any information you would like to share pertaining to your child’s assessment, please forward it to the person named below or bring it to the meeting.
I HAVE REVIEWED THE ENCLOSED BROCHURE CONCERNING THE RIGHTS OF CHILDREN WITH DISABILITES AND PARENT RESPONSIBILITES. ____ YES ____ NO
Please check one of the following:
____ I give permission for an individual assessment.
____ I do not give permission for an individual assessment.
Date: ______Signature of Parent or Guardian ______
Phone: ______Address: ______
______
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Assistive Technology
General Information Form
Student______DOB______
Primary Diagnosis______
Secondary Diagnosis______
District______School______
Educational setting:
_____Inclusion _____Resource _____Self-contained ______Homebound
Attendance: ____ Full school day ____ Abbreviated schedule (specify:______)
Disability (check all that apply)_____Autism / _____Multiple Disabilities
_____Blind / _____Orthopedic Impairment
_____Deaf-Blind / _____Other-Functional Delayed
_____Developmental Delay / _____Other Health Impairments
_____Emotional Disturbance / _____Specific Learning Disability
_____Hearing Impaired / _____Speech Impairment
_____Intellectually Gifted / _____Traumatic Brain Injury
_____Language Impairment / _____Visual Impairment
_____Mental Retardation / _____Other
What is the primary need for AT support? Indicate all that apply.
Communication Functional skills Academic skillsWritten ExpressionReading Math Computer Access Handwriting Universal Access Vision impairment Hearing Impairment Other______
Academic Skills
Is student on grade level? ___ Yes ___ No If no, what grade level is student presently working on? ______
Self-Help/Independence Skills
Does the student need assistance with any of the following tasks at school?
_____feeding _____dressing _____toileting ____communication
Are there any behaviors (both positive and negative) that significantly impact the student's performance? ______
Are there significant factors about the student's strengths, learning style, coping strategies, or interests that should be considered? ______
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Classroom Skills
CHECKLIST
Explain specific issues or limitations affecting any of the following areas:
Study Skills
______
Reading Skills______
What is current reading level? ______
Writing Skills______
Math Skills
______
Science/Social Studies Skills
______
Is student using any of the following Assistive Technology devices?
(Check all that apply)
Devices & Equipment / Tech Tools / SoftwareAugmentative Communication Device
(GoTalk, Dynavox, etc.)
______/ Writing aids
(pencil grips, note taker,
raised line paper, etc.)
______/ Academic software supports
______
Computer
(desktop, laptop, iPad or
other Tablet)
______/ Low tech strategies forcommunication (pictures, object choices, schedules, etc)
______/ Multi-modal supports for instruction
______
Portable word processor
(NEO, Dana, iPad etc.)
______/ OTHER:
______
3 / Word prediction
(Co:Writer, WordQ, etc)
______
General Technology Access
CHECKLIST
Hand preference: ______Left _____ Right _____Limited hand use
Student can:
Make consistent eye contact / Move at least 1 body part freelyTurn head for gaze / Identify: ______
Nod head or gesture for responses / Point with whole hand
Cross midline / Maintain switch closure
Which hand? R or L
Point with 1-2 fingers
Maintain accurate point / Write with a pen/pencil
Grasp objects
What is the smallest area to which the student can point ? (e.g. 1” x 1”)
______
What is the student’s widest range of access? (e.g., front/center reach, laptray, beyond laptray, down to side, etc) ______
Does student have word processing skills? ____Yes ____NO
Have any of these devices been tried with the student?
Computer _____ Touchscreen _____ Adaptive Mouse or Joystick ______
Adaptive keyboard ______Tablet _____ Other _____
Was the student successful? ______
Does the student:
_____Walk Independently ______Walk with device support
_____Use a wheelchair
*manual _____ *power ______*type of control system ______
Identify any switches that have been tried with student. Indicate those that worked best for the student.____Button ____Pinch ____Leaf ____Plate _____String ____Wobble
____Microlight ____Sip-n-Puff _____Flat ____Touch Sensitive ____Infrared
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What means of access has been tried? Note right or left where appropriate.
_____Cheek _____Chin _____Head _____Eye _____Elbow _____Forearm _____Elbow _____Hand _____ Knee _____Foot
Identify any adaptive access devices or software supports given trial use:
____________
______
______
Specific concerns ______
______
______
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Communication Skills
CHECKLIST
Describe, in general, how the student currently communicates. Include meaningful behaviors in your descriptions.
What objects/events/people will motivate the student to communicate?
______
Identify AAC systems and strategies that have been tried. Identify those that were successful.
Non Picture Based:
____gestural system ____object board ____object schedule
Picture Based:
____picture board ____picture book
____digital images ____black/white icons ____colored icons
Which of the following are used by the adultto elicit a response from the student?
____digital pictures ____drawn icons ____simple directives ____gestures ____sign language ____object cues ____Yes/No gestures ____simple phrases
____visual cues paired with verbal prompts
Which of the following forms of communication areused by the student?
____eye contact ____smiling ____whole body gestures ____Yes/No gestures ____sign language ____utterances ____single word responses ____simple phrases ____pointing to digital pictures ____pointing to drawn icons ____written text
____pointing to object cues ____voice output AAC systems
Can the student use connected speech? ____yes ____no
Communication Systems
Identify any communication systems or strategies that have been tried or that the student currently uses:
______
______
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Writing Skills
CHECKLIST
Current writing ability/mechanics
Can hold regular pencil / Can copy simple shapesCan hold pencil when adapted with: ______/ Can copy simple words
Holds pencil, but does not write / Can copy from board
Can print a few words / Can write on 1" lines
Can print name / Can write on narrow lines
Can write cursive / Can use spacing correctly
Writing is limited due to fatigue / Can size writing to fit spaces
Writing is slow and arduous / Can write independently and legibly
Assistive technology tried
Paper with heavier lines / Paper with raised linesPencil grip / Special pencil or marker
Splint or pencil holder / Typewriter
Slant-board
Composing Written Material
____ word processor _____ Voice recognition software
_____Word cards/word book/word wall _____Word processor w/ word prediction _____word prediction on computer ____ Talking dictionary/thesaurus/spell checker
_____Multimedia software for expression of ideas
Computer use:(Check all that apply)
Has student used computer before? ____Yes ____No
Is there a computer in the home? ____Yes ____No
What platform is the student currently using? ____Mac ____PC
Identify supports currently in use: ______
Summary of student’s keyboarding abilities:
____ does not type ____can tap desired key on command
____types slowly with one finger____types slowly with more than one finger
____10 finger typing____uses adaptive keyboard(BigKeys, Intellikeys)
____one-handed typing: Left or Right
____uses special access software
(*onscreen keyboard, scanning arrays, voice recognition, etc)
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Reading Skills
CHECKLIST
Current reading ability
No visual limitations / Recognizes some sight wordsCan read simple words with assistance/cues / Can read aloud
Recognizes letters/sounds / Can read from board
Needs visual supports for cueing / Can re-tell simple facts/info
Can decode words / Prefers picture books
Reading Supports given trial use
Audio books on computer / Picture books with/without voice
eBooks with audio support / Reading books to student
eBooks without support / Text highlighting support
Text To Speech
Other ______
______
Specific concerns: ______
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