Assistive Technology
Intervention Worksheet
Student Name: _____________________ Age: __________________
Evaluator(s): ______________________________________________
Fill out one worksheet for each piece of equipment you trial. Use the information to write the assistive technology report.
You should trial at least two (2) equipment options for each category of assistive technology. For example, if your student needs a device for near/far viewing, trial two devices that can accomplish this task (such as a
VisioBook and a Transformer). This may not apply in some cases, but will in many.
Feel free to change worksheet to meet individual needs.
Name of Equipment ____________________________________________
Check general category of Device being trialed:
_____Near/Far Magnification _____Stand-alone Magnification
_____Hand-held magnification
_____Braille Note Taker
_____IOS Device
_____Book Reader
_____Other _______________ _____Other _______________
Specific Device __________________________________________
Trial Environment(s):__________________________________________
Future Environments that Assistive Technology may be needed in:
____________________________________________________________
Trial Data
Suggested Scoring Guide:

I = independent
Your own Scoring Key:
V = verbal cue(s) P = physical assist(s)
__________________________________________________________
__________________________________________________________
____________________________________________________________
Data Collection
Task evaluated with equipment being trialed Date/
Result
Task 1:
Task 2
Task 3
Task 4
Task 5
Task 6
Task 7
Task 8
Date/
Result
Date/
Result
Date/
Result

Reflection
Do you feel this trial was a success? Explain.
Did the student express or demonstrate any likes or dislikes toward the device being trialed? Explain.
According to staff (such as paraeducator or classroom teacher) what were strengths and weaknesses of the device being trialed?
What are your next steps?
_____Trial additional equipment
_____Recommend the purchase of assistive technology by the LEA
_____Write a report to submit to LEA
_____Other_____________________________________
Any additional comments:
Rosa Mauer 1/11/2013