Lake Agassiz Special Education Cooperative
Assistive Technology Consideration Form
Student Name: ________________________________
Birth Date: ____________________________
School: ____________________________________
Grade: ______________________________
School Phone: _______________________________
Teacher: _____________________________
Parent or Guardian: _____________________________
Federal Setting/Disability:_____________________
Other Agencies Involved: _________________________________________________________________
Classroom setting where concerns are identified:
___Community Setting
___Resource Room
___General Education
___Music
___Recess
___Home
___Day Care
___Small Group Participation (participation/transition)
** indicate PS for para support if provided in that setting
___ P.E.
___Headstart
___Lunch
___ECFE
Current Related Services
__Adapted P.E.
___Occupational Therapy
___Speech/Language Therapy
__ Nursing
___Physical Therapy
___B/VI
__Other Organizations Providing Services _______________________________________________
___DHH
___O & M
Medical Considerations
Medical Diagnosis: ___________________________________________________________________________________________
Comment___________________________________________________________________________________________________________
Areas of Concern
___ Section 1 Fine Motor Related to Computer or Device Access
___ Section 8 Recreation and Leisure
___ Section 2 Motor Aspects of Writing
___ Section 9 Seating and Positioning
___ Section 3 Composing Written Material
___ Section 10 Mobility
___ Section 4 Communication
___ Section 11 Vision
___ Section 5 Reading
___ Section 12 Hearing
___ Section 6 Learning and Studying
___ Section 13 Self Care
___ Section 7 Math
What aspect are you concerned with?:
Why are you concerned?:
Lake Agassiz Special Education Cooperative
Fine Motor Related to
Computer Access
Word Prediction, word
completion applications
Key guard
Voice Over Apps (Screen
Readers)
You tube links of texts
Learning and Studying
Daily Planner
Alternative Mouse
Wheel Chair
Scooters
Car Seats
Adapted Seatbelts
Cane
Alternative Keyboard
Print or Picture Schedules
GPS Device
Mouth Stick
Color Tabs, Colored Paper,
Folders, Post it Notes
Vision
Large Print Book
Switches
Touch Screen
Voice Recognition
Graphic Organizers
Concept Maps
Color Background
Light
Slantboard
Applications for- Organization,
Calendar, Daily Planners,
Flashcards, Scheduled locking of
device functioning, timers
Recorded Materials
Zoom Applications
Portable Word Processor
Lined Paper
Math
Number line/Number Chart
Hearing
Hearing Aides
Composing Written Materials
Word Cards, Word Book, Stamps
Calculator
Accessible Dictonary/Thesarus
Large Calculator
Spell Check
Graph Paper
Self-Care
Voice Over for Word Questions
Velcro Fasteners
Word Processor
Clocks, rulers
Button Hook
Voice Recognition Software
Overlay Maker
Voice Over for Story Problems
Graphic Organizers
Recreation and Leisure
Adapted Toys and Games
Communication
Communication Board
Switches
Adaptive Tooth Brush
Eye Gaze Board
Adapted Sporting Equipment
Shoe Horn
Voice Output Applications
(Proloqoe, Tap to Talk, ect)
Cuffs to Hold Crayons, Markers,
Paint Brush
Picture Schedule
Typing to Speech Applications
Modified Utensil (Rollers,
Stompers, and Scissors)
Motor Aspects of Writing
Adapted Pen/Pencil Grips
Voice output with Item
sequencing (Eg: Macaw or
Digivox)
Reading
Book adapted for page turning
(page fluffers)
Drawing Computer Programs
Music/Game Applications
Seating/Positioning
Stander
Blocks
Reading Pens
Ball
Adaptive Books
Alternative chairs
Book Share
Mobility
Walker
Digital Copies of text
Grab Bars
Colored Pens/Markers
Digital Reader
Closed Captioning
Amplifiers
Dressing Aids
Adapted Utensils
No Slip Materials
Toileting Aids