Assistive Technology Referral Packet
SAN MATEO COUNTY OFFICE OF EDUCATION
Please fill out the following items completely and all that pertain to your student on Pg. 1-5.
Student Information
Student Name:
Date of Birth:
School Name:
School Address:
School Phone:
Parent(s) phone:
Grade:
Briefly describe the reason that this student has been referred for an Assistive Technology
Assessment: (What is the student not doing now that you would like to see him/her doing
using technology?
Contact Information:
Contact person for assessment appointment: (i.e., teacher, RSP, OT, etc)
Name:
Phone:
Title:
Teacher: (Special Education, Resource Specialist, Regular Education Teacher)
Name:
Title:
Phone:
Support Personnel: (Speech, Inclusion, OT, or Aide)
Name:
Title:
Phone:
__________________________________________________________________________
Timeline (60 days): Assessment Plan signed by parent(s) _
Referral received by COE _
(date)
(date) IEP needs to be held by:
It is imperative that the referral be received in a timely manner in order that the assessment
may be completed within 60 days from the date that the assessment plan has been signed by
the parent(s).
Student Services Division
65 Tower Road  San Mateo, CA 94402  (650) 573-4010  Fax (650) 573-4056
1
Assistive Technology Referral Packet
SAN MATEO COUNTY OFFICE OF EDUCATION
Eligibility Criteria: How has this student been found eligible for special education services?
Low Incidence:
Yes
No If yes, check one:
Other eligibility:
Speech & Lang
Intellectual Disability
VI
HI
OI
Other Health Impaired
Autism
Traumatic Brain Injury
Emotional Disturbance
Other
Specific Learning Disability
__________________________________________________________________________
Hearing/Vision Information:
Date of last Audiology exam:
Hearing loss identified:
right ear:
Mild
Moderate
Severe
Profound
left ear:
Mild
Moderate
Severe
Profound
Date of last vision report:
Report indicates:
__________________________________________________________________________
Related Services: Please note minutes per week for each service
Speech
Occupational Therapy
Physical Therapy
Vision Services
__________________________________________________________________________
Medical Considerations: Check all that apply
history of seizures
multiple health problems
fatigues easily
wheelchair
degenerative medical condition
frequent ear infections
frequent pain
frequent upper respiratory infections
medication for seizure control
__________________________________________________________________________
Current Academic Level:
Reading
Reading Comprehension
Reading Fluency
Writing
Writing Fluency
Spelling
Please provide writing samples for this student if it is an area of concern.
Math
Student Services Division
65 Tower Road  San Mateo, CA 94402  (650) 573-4010  Fax (650) 573-4056
2
Assistive Technology Referral Packet
SAN MATEO COUNTY OFFICE OF EDUCATION
Wheelchair:
Please indicate how much of the day student is in a wheelchair:
Complete for wheelchair students:
All
Part
uses a standard chair and desk
uses an adapted chair or adjustable table
uses wheelchair tray
there are concerns regarding seating
there are concerns regarding head control
__________________________________________________________________________
Fine Motor: As it related to writing, computer use or device access: Please elaborate for
each area checked:
Range of motion is limited
Abnormal reflexes or muscle tone
Accuracy (for example, can student target and hit keys on a keyboard)
Suffers fatigue; throughout the day or at a particular time(s) of the day
__________________________________________________________________________
Computer Use:
Standard keyboard and/or mouse
Keyboarding :
Touch Type
Hunt and peck
Adaptive Software: for example; Co:Writer, Inspiration)
Give examples:
Adaptive Keyboard and/or mouse (for example: IntellikKeys, Big Keys, TrackBall)
Computers available in class or on campus:
Platform:
PC, please indicate version of Windows: W98, W2000, WXP, other:
Apple, please indicate op. system: pre-OS9, OS9, OSX, other:
Number of computers available:
Number of printers available:
How frequently does the student use the computer? What type of use?
daily
several times per week
to access commercial software titles (fun)
to type papers, journals, reports
Are there any concerns related to computer input that you can identify?
Student Services Division
65 Tower Road  San Mateo, CA 94402  (650) 573-4010  Fax (650) 573-4056
3
Assistive Technology Referral Packet
SAN MATEO COUNTY OFFICE OF EDUCATION
Adaptations and Modifications: Check all that apply
Adaptations:
pencil grip
paper with raised lines
splint or pencil holder
special pencil/marker
computer with spell check
word prediction software
enlarged text
books on tape
tests read to student
grid paper for math
writing templates
more time for assignments
more time for tests
digitalized text materials
use of graphics to illustrate
note taker
scan and read program
talking word processor
other (explain)
Modifications:
reduced amount to read
reduced number of math problems
lowered reading level
lowered math level
Franklin Speller
calculator
adapted math software
alternative means of demonstrating knowledge
dictating journals
multi-media presentation ILO reports
reduced assignments or homework
other (list)
Please list student strengths, needs, parental concerns:
Strengths:
Needs:
Parental Concerns regarding progress on student’s goals:
Student Services Division
65 Tower Road  San Mateo, CA 94402  (650) 573-4010  Fax (650) 573-4056
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Assistive Technology Referral Packet
SAN MATEO COUNTY OFFICE OF EDUCATION
Communication
Please complete only if concerns are concerning student’s communication skills.
Current levels:
Receptive Language (Age Equivalent):
Expressive language (Age Equivalent):
Communication/social interaction skills:
Check all that apply to student’s communication skills.
turns towards speaker
interacts with peers
is aware of listener’s attention
initiates interactions
asks questions
responds to communication interaction
requests clarification from communication partner
repairs communication breakdowns
requires frequent verbal prompts to initiate
requires frequent verbal prompts to stay on topic
requires frequent physical prompts
requires visual cues for complete sentences
communicates with one-word or abbreviated speech
uses an augmentative (additional) communication system in addition to speech
uses an augmentative (additional) communication device in addition to speech
uses an augmentative (replacement) communication system instead of speech
uses an augmentative (replacement) communication device instead of speech
Please identify the communication system components or communication device this student
uses:
Please identify below which nonverbal means of communication this student currently uses:
eye-gaze, eye-movement
body position, orientation, changes
gestures
facial expressions
reliable YES/NO
pointing
2-3 word utterances
sign language
sign language approximations
communication board:
object based
photo-based
icon based
word based
communication device/system
Please identify device:
Number of icons student can scan
and size
(i.e., 1”, 2”, 3”, 4”)
Student Services Division
65 Tower Road  San Mateo, CA 94402  (650) 573-4010  Fax (650) 573-4056
5