ASSISTIVE TECHNOLOGY INTAKE FORM
Identifying Information:
Student Name:
Date of Birth:
Home School District:
Age:
School Attending:
Grade:
School Address:
Kindergarten:
Classroom Teacher:
Arrival Time:
Email Address:
Departure
Time:
LEA:
Phone:
Email Address:
Fax:
AM
Person(s) Completing
Forms:
Position/Relationship
to Student
Date Form
Completed:
Assignment (for office use only)
LATC
Date
Please return this form to:
Susan Moskal – Intermediate Unit 1 – One Intermediate Unit Drive – Coal Center PA 15423
Fax: 724-938-6665
PM
Please answer the following questions to maximize the referral:
1. Description of Need:
What type of assistive technology are you currently seeking?
Communication Device
Writing Tools
Computer Access (PC or Mac)
Environmental Control
Vision
Hearing
How do you think assistive technology may help the student? Check a maximum of 3
Practice academic skills
Provide activities for recreation/leisure
Provide access to computers
Assist with spelling
Increase reading comprehension
Improve the quality of written composition
Assist with organization of school work
Provide access to the Internet/leisure
Provide an efficient means of note taking
Increase the speed of his/her typing
Enable him/her to take tests and demonstrate
Other:
what s/he knows
Does the student currently use any assistive technology?
YES
NO
If YES, please select from the list below (Check all that apply):
Augmentative/Alternative Communication System
Name of System: ___________
Manual Wheelchair
Power Wheelchair
Low Tech Writing Aids
Low Tech Vision Aids
Manual Communication Board
Computer – Type (platform):
Adaptive Input - Describe:
Adaptive Output – Describe:
Voice Recognition
Word Prediction
Amplification System
Environmental Control Unit/EADL
If NO, has the student used any assistive technology in the past?
YES
NO
If YES, please select from the list below (Check all that apply):
Augmentative/Alternative Communication System
Name of System: ____________
Manual Wheelchair
Power Wheelchair
Low Tech Writing Aids
Low Tech Vision Aids
Manual Communication Board
Computer – Type (platform):
Adaptive Input - Describe:
Adaptive Output – Describe:
Voice Recognition
Word Prediction
Amplification System
Environmental Control Unit/EADL
2. Description of Disability:
Does the student have a disability?
YES
NO
If YES, please select from the list below.
Autism
Emotional Disturbance
Orthopedic Impairment
Other Health Impairment
Deaf-Blindness
Intellectual Disability (Mental Retardation)
Hearing Impairment, including Deafness
Specific Learning Disability
Visual Impairment, including Blindness
Speech/Language Impairment
Traumatic Brain Injury
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3. Description of Educational Services:
Does the student have a current IEP?
If YES, please attach a copy of the IEP and ER/RR.
YES
NO
Does the student receive any support services?
YES
If YES, please check the services receiving:
Speech/Language Support
Vision Support
Hearing Support
Medication
Physical Therapy
Behavior Management
Occupational Therapy
Other:
NO
Is there an IEP team in place?
If YES, check and list appropriate team members:
Check
Role
Student
Parent(s)
Speech & Language Pathologist
Occupational Therapist
Physical Therapist
Behavioral Specialist
Special Education Teacher
Regular Education Teacher
Paraprofessional
Psychologist
Teacher of the Visually Impaired
Teacher of the Hearing Impaired
Educational Audiologist
Counselors
Principal
LEA
Supervisor
Agency Representative
Therapeutic Staff Support
NO
YES
Name(s) print clearly
3
4.
Description of Abilities:
Communication: Check all that the student uses and underline primary method the student uses.
Changes in breathing patterns
Vowels, vowel combination
Eye-gaze/eye movement
List examples:
Facial expressions
Semi intelligible speech
Gestures
Estimate % of intelligible:
Pointing
Single words
Sign language (few combinations)
List examples and approx. #:
Sign language (many combinations)
Communication board
Body position changes
Tangibles
Pictures
Reliable No Response
Combo picture/symbols
Word
Reliable Yes Response
Voice output device, Specify:
Two word utterances
Intelligible speech
Three word utterances
Writing
Vocalizations
Other:
List examples:
To indicate “yes” and “no”, the student: Check all that the student uses.
Shakes head
Vocalizes
Signs
Gestures
Eye gazes
Points to board
Uses word approximations
Does not respond consistently
Can a person unfamiliar with the student understand the response?
Most of the time
Sometimes
Rarely
Does this student have difficulty with written work?
Writing: Check all that apply.
Holds pencil, but does not write
Pretend writes
Scribbles with a few recognizable letters
Uses regular pencil
Uses a pencil adapted with
Copies simple shapes
YES
Writes on 1" lines
Writes on narrow lines
Prints name
Writes cursive
Uses spacing correctly
Writing is limited due to fatigue
Copies from book (near point)
Copies from board (far point)
Prints a few words
Hand Dominance
Right Hand
NO
Sizes writing to fit spaces
Writing is slow and arduous
Writes independently and legibly
Left Hand
Not established
Approximately what percentage of the student’s writing is legible?
0%
25%
50%
75%
4
100%
What percentage of the student’s written work contains correct spelling?
0%
25%
50%
75%
100%
Is handwritten work completed in the same time frame as peers?
YES
NO
Please check the type of work used during the school day, the approximate amount of time spent on this, and
whether the student is successful in completing this type of written work:
Check
Type of work
Amt of time
Successful
Y or N
Fill-in-the-blank worksheets
Short Answer (phrase/single sentence)
Short in-class assignment (1-4 paragraphs)
Reports or longer written assignments (more than 1
page)
Note taking
Written homework
Written work:
Short assignments:
Writes independently
Asks for minimal assistance
Dictates to another writer
Other:
Uses computer
Reports:
Writes independently
Asks for minimal assistance
Dictates to another writer
Other:
Uses computer
School Computer Use: Check all that apply and list titles of software
Word processing
Academic skills practice
Internet browsing
Other:
Student does not use computer at school
Computer availability at school:
Mac (version_______)
Windows 2000 XP
Windows Vista
Windows 7
Microsoft Office version:
2010
2007
2003
Earlier version
Current mouse/mouse alternative use: Check all that apply.
Uses mouse:
Independently
With assistance
Uses adaptive equipment:
Trackball
Touch screen
Joystick
Other:
Head pointer
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Current Keyboarding Ability: Check all that apply.
Does not currently type
Types with 10 fingers and correct hand position
Types with one finger
Accidentally hits unwanted keys
Types with several fingers
Uses adapted / alternate keyboard
Uses one hand
Specify:
Uses two hands
Attention Level:
Attends appropriately
Very short attention span
Behavior:
Self-stimulatory
Escape/Runner
Has difficulty staying on task
Attention Seeking
Avoidance
Aggressive
Other:
Sensory Processing:
Vestibular
The vestibular system is located in the inner ear. It allows us to detect movement, speed, direction, and where
our body is in space. Vestibular input stays in the nervous system for four to eight hours. Linear movements
(i.e., rocking and swinging) are calming; circular movements (i.e., spinning) are stimulating. Some signs of
dysfunction include fear of heights, difficulty sitting still, rocking or spinning excessively. Some students dislike
tilting their heads or being upside down. A child with vestibular processing impairments may appear to be
clumsy and lack typical motor movement coordination.
Specify:
Proprioception
Proprioception is the way receptors in our joints perceive muscle movements. These receptors allow us to
coordinate movements. Proprioceptive input stays in the nervous system for up to 90 minutes. Students who
have issues with this system might apply too much pressure when writing or coloring, seek pressure or appear
too rough when touching other children or animals.
Specify:
Tactile
The tactile system works through receptors in our skin which provide us with information about temperature,
pressure, touch, and pain. This information helps to alert us of danger in our environment. Tactile input stays
in the nervous system for approximately 90 minutes. Cold or rough input is stimulating, while deep pressure
and warmth are calming. Some children may have difficulty discriminating tactile information, making fine
motor tasks (e.g., holding a pencil, using scissors, or opening containers) more difficult. Individuals who are
tactilely hypersensitive (tactilely defensive) may dislike finger painting and using glue or clay, and may be
bothered by tags in clothing or by certain materials. People who are tactilely hyposensitive (sensory seeking)
may seek additional input by mouthing objects and/or constantly touching things, such as textured items.
Specify:
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Auditory
The auditory system utilizes the structures of the ear, picking up sound waves and then sending those waves to
the temporal lobe of the brain (directly above the ear) for interpretation. This system helps to facilitate
communication, determine where sounds are coming from, and to differentiate between sounds. Auditory
processing dysfunction is not a hearing impairment. Students who have problems with auditory processing
may have a normal decibel range, but have difficulty organizing, interpreting, or remembering auditory input.
Some children may not be able to filter out background noises, while others may be extremely sensitive to
auditory stimulus. For example, students who have auditory processing difficulties may cover their ears when
they are exposed to sudden or loud noises. They may have trouble determining where a sound is coming from,
or be distracted by seemingly normal background noises. Additionally, you may notice some delay or confusion
when following verbal directions.
Specify:
Visual
The visual system is made of several components: acuity, ocular motor function, visual motor coordination,
and visual perception. Acuity is the ability to focus; it’s how clearly we see objects. Ocular motor function
allows us to move our eyes across a given field without turning our heads (tracking). Visual motor coordination
allows us to coordinate movement like handwriting or dribbling a basketball (hand-eye coordination). Visual
perception, the interpretation of visual stimulus (input), helps us to find patterns, discriminate between like
objects (i.e., b, d, p, q), and to make visual sense of the world around us. Students who have poor visual
processing skills may have trouble maintaining eye contact, transferring information from one page to another
or the board, or keeping their place while reading.
Specify:
Olfactory
The olfactory system is our sense of smell. Smells are processed in the limbic system. This is the same part of
the brain that is responsible for emotional memory, motivation and for storing long term memory; therefore
certain smells can evoke memories. Some children may be sensitive to even typically pleasant or normal
smells, causing them to engage in atypical stress responses.
Specify:
Gustatory
The gustatory system includes taste and oral motor function. Input to this system can be either calming or
alerting to the nervous system. Foods that are salty, sour, or cold can be alerting, while foods that are sweet or
warm are calming. Certain oral motor activities can have similar effects. Activities like chewing gum may help
to increase alertness, focus, and concentration, while sucking and blowing are calming and help to relieve
stress. Students with dysfunctions in these areas may complain or react adversely to smells or be picky eaters,
preferring to eat foods with familiar tastes and textures.
Specify:
Student’s Learning Style:
Auditory
Multiple Modalities
Visual
If so, please list:
Kinesthetic
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What difficulties does the student have in learning new material or studying? Check all that apply.
Remembering assignments
Organizing materials for a report or paper
Reviewing notes from lectures
Taking notes during lectures
Remembering steps of tasks or
Organizing information / notes assignments
Turning in assignments
Finding place in textbooks
Other:
Motor:
WNL
Decreased Range of Motion
Abnormal Reflexes/Muscle Tone
Fatigue
Seating/Positioning: Check all that apply.
Sits in regular chair with feet on floor
Sits in regular chair with support under feet
Sits in adapted chair
Sits in wheelchair
Has difficulty using table or desk
Description of Seating:
Seating provides trunk stability
Seating provides 90/90/90 position
Best position for head control is:
Please specify:
Desk Accessibility:
Uses regular desk
Uses wheelchair for desktop
Hearing:
Within Normal Limits
Hearing Loss:
Type of Loss:
Seating allows feet to be on the floor
Has difficulty with head control
Uses desk with height adjusted
Right Ear
Conductive
Left Ear
Sensorineural
Uses adapted table
Bilaterial
Central
Aided
Mixed
Date of last audiological evaluation:
Vision:
Within Normal Limits
Loss of Vision:
Severity of Loss:
Right Eye
Low Vision
Left Eye
Legally Blind
Corrective Lenses
Completely Blind
Date of last vision evaluation:
Medical Considerations:
History of seizures
Has frequent pain
Has frequent ear infections
Has allergies to
Currently taking medication for
Other – Describe briefly
Fatigues easily
Has degenerative medical condition
Has digestive problems
Has multiple health problems
Has frequent upper respiratory infections
Include Additional Information, Questions and Concerns:
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