Assistive Technology
Intervention Worksheet
Student: _____________________________ Age/Grade: ______
Evaluator: ___________________________
Other Information: _____________________________________
Write the name of the device, such as IPad or BrailleNote, being trialed
for up to 6 weeks (or less when possible). After the 6 weeks, a team
decision should be made as to whether the school district will purchase the
device. At the end of the 6-week trial, the device should be returned to the
Assistive Device Center.
Name of Device __________________________________________
Use the table below to keep data regarding use of the device. More than
one date/score column is provided so that you may use the chart for data
collections at the beginning, middle, and end of the trial.
This intervention assessment is general in nature. Specific skill
development goals may be written and rubrics for assessment may be
developed upon purchase of equipment by the local education agency.
Feel free to change the information to meet the needs of your particular
situation.
Use the information generated from the worksheet to write a
recommendations report regarding the assistive technology being trialed.
I = independent
V = verbal cue(s)
p = physical assist(s)
F = possible future use
N = not applicable at this time
Skill/Concept
Date
Date
Date
Score Score Score
1. Use fine motor skills to navigate and manipulate
device.
2. Demonstrate motivation and willingness to use
device to meet goals.
3. Student is able to determine, request, or make
adjustment to settings as needed.
4. Student cares for device appropriately (does not
drop, stores in backpack, etc).
5. Use device for reading
_____ braille
_____ print (indicate preference)
____Auditory
6. Complete written tasks using device:
_______ using braille (refreshable display)
_ _____ using on-screen keyboard
_______ using qwerty keyboard
_______ using dictation
_______Hand writing
_______ Fill out test or worksheet
_____ _Other___________________
7. Send and receive e-mail.
8. Use Internet.
9. Keep track of assignments (calendar).
10. Communicate with others appropriately (such
as through Skype or face time, other).
11. Download and/or access books.
_____Bookshare _____ Learning Ally
_____ IBooks _____BARD
_____ Read items such as hard copy textbooks,
worksheets, tests, etc. (close viewing).
_____Other_________________________
12. Look up words with dictionary/thesaurus
13. Use device for appropriate leisure activities
(listening to music, etc).
14. Use educational apps as needed (such as math
apps, CVI apps, etc).
15. Use GPS for navigation.
16. View teacher display (such as white board) using device.
17. Charge (hook and unhook from AC power, know when) as
appropriate.
18. Communicate with others regarding device (what device can and
cannot be used for, etc).
20. Use phone or texting as appropriate.
21. Other
22. Other
Total Independent Score
Comments
Think about…
1. Did the device provide adaquate accessibility options for the student?
Explain.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
2. Did the student show improvement during the trial of this device? Give
narrative to describe your observations and results of data.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
3. Do you believe continued improvement could be made if student had
this device permanently? Explain.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
4. What training would be necessary for student to make full use of this
product? How could this training realistically be provided? Who would
give instruction?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
5. What would staff needs regarding training would assist the student to
take complete advantage of this product. Write details as possible.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
6. Considering the above data, what would your next steps be? Why?
Outline the data that helped in your decision making if possible.
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
7. Will this device “grow with” the student? Based on the data, your
observations, ect. Explain.
_______________________________________________________________
_______________________________________________________________
8. What is your plan to communicate results to team members?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Rosa Mauer 11/30/2012