Region One Education Service Center
VI/Assistive Technology Project
Student Referral Guide
Student Name ____________________ DOB __/__/__ Age_______ Grade_______
School __________________________ Teacher ____________________________
Date of ARD requesting Assistive Technology Evaluation _____________________
Disability: (Check all that apply)
Auditory Impairment
Emotional Disturbance
Multiple Disabilities
Other Health Impaired
Visual Impairment
Autism
Learning Disability
Non-Categorical
Speech Impairment
Deaf-Blind
Mental Retardation
Orthopedic Impairment
Traumatic Brain Injury
Physical Therapy
Other ______________
Related Services Received:
Occupational Therapy
Check the areas of concern and complete the appropriate sections of the guide.
Mechanics of Writing
(Pages 6-7)
Computer/Device Access (Pages 4-5)
Composing Written Material (Pages 7-8)
Communication (Pages 5-6)
Reading
(Page 8)
Study Skills
(Page 8-9)
Math
(Page 9)
Recreation and Leisure (Pages 3-4)
Seating and Positioning (Page 3)
Mobility (Page 3)
Vision
(Page 2)
Hearing (Page 2)
Current Technology:
List any assistive technology (including computer hardware and software) being currently
used by the student:________________________________________________________
________________________________________________________________________
What type of computer is available for student use? ______________________________
Typical school platform: ___________________________________________________
Additional Information: __________________________________________________
_______________________________________________________________________
Person completing form: __________________________________________________
Region One VI/Assistive Technology Project (2001)
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Current Student Status
Vision (Should be completed by Vision Teacher)
Acuities if known: __________________
Eye Condition: ________________________________________________________
Visual Abilities: (Check all that apply)
Can read standard textbook print
Reads large print in ______ size font
Requires special lighting such as __________
Requires specialized positioning of materials such as__________________________
Currently uses a Closed Circuit Television
Currently uses a magnification software: _____________________ at ___________X
Currently uses a screen reader software: ____________________________________
Current Technology:
Currently uses taped materials versus print or Braille
Currently uses Perkins Brailler
Currently uses Braille note taking device: ___________________________________
Summary of student’s abilities and concerns related to vision:
________________________________________________________________________
________________________________________________________________________
Hearing (Should be completed by Auditorially Impaired Teacher)
Hearing Loss identified: Right ear
Left ear
Mild
Moderate
Severe
Profound
Mild
Moderate
Severe
Profound
Hearing Abilities: (Check all that apply)
Attends to sound
high pitch
low pitch
voices
background noises
Discriminates environmental vs. non-environmental sounds
Turns toward sound
Can hear some speech sounds
Can understand synthesized speech
Student Communication Mode: (Check all that apply)
Speech
Gestures
Signs
Picture Cues
Speech and sign together
Written messages
Is there a discrepancy between receptive and expressive abilities? Yes No
If yes, describe further: _____________________________________________
Region One VI/Assistive Technology Project (2001)
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Summary of hearing abilities and concerns: ___________________________
_________________________________________________________________
Seating and Positioning:
Student’s current seating and positioning: (Check all that apply)
Sits in regular chair
Uses tray on wheelchair
Sits in adapted chair
Uses adapted table
Sits in wheelchair
Maintains head control
Uses regular desk
Spends part of day out of chair for prescribed
Uses desk with height adjusted
positioning
Summary of student’s abilities and concerns related to seating and positioning:
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Mobility
Student’s current mobility abilities: (Check all that apply):
Walks independently
Uses manual wheelchair, independently
Walks with assistance
Uses power wheelchair, independently
Has difficulty walking
Walks with appliance
Is pushed in manual wheelchair
Summary of student’s abilities and concerns related to mobility:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Region One VI/Assistive Technology Project (2001)
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Recreation and Leisure: (Check all that apply)
Handles/manipulates objects
Throws/catches objects
Operates TV, VCR, Computer, CD Player, etc.
What activities does the student enjoy? ___________________________________
_____________________________________________________________________
Current technology: (Check all that apply)
Toys adapted with Velcro, magnets, etc.
Modified utensils, e.g Brushes
Switch operated toys
Universal cuff or strap
Adaptive sporting equipment
Software on computer
Summary of student’s abilities and concerns in the area of Recreation and Leisure:
______________________________________________________________________
______________________________________________________________________
Computer/Device Access:
Current fine motor abilities: Observe the student with paper and pencil, computer,
switches, etc. Look at the movements as well as the activities and environment. Does the
student have voluntary, isolated, controlled movement using: (Check all that apply)
Left hand
Right hand
Eye(s)
Left arm
Right arm
Head
Left leg
Right leg
Mouth
Left foot
Right foot
Tongue
Finger(s)
Eyebrows
Other: ______________
Briefly describe the activities observed: ___________________________________
___________________________________________________________________
Range of Motion: Student has limitations in range of motion:
Yes
No
If yes, describe specific range in which the student has the most motor control:
___________________________________________________________________
Region One VI/Assistive Technology Project (2001)
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___________________________________________________________________
Abnormal reflexes and muscle tone: Student has abnormal reflexes or muscle tone:
Yes
No If yes, describe the abnormal reflex patterns or patterns of low or high
muscle tone: _________________________________________________________
____________________________________________________________________
Accuracy: Student has difficulty with accuracy:
Yes
No
If yes, describe the difficulties with accuracy: _______________________________
____________________________________________________________________
Fatigue: Student fatigues easily:
Yes
No
Direct Selection Method: (Check those that apply)
Finger
Head pointer/stick, mouth stick
Hand
Light beam/laser
Pointers, hand grips, splints, etc.
Eye Gaze
Grid size that student is able to access accurately:
1”
2”
3”
4”
Number of squares across _____________ Number of squares down ___________
Scanning: If student cannot direct select, does the student use scanning?
Yes
No If yes:
Step
Automatic
Inverse
Preferred control site (body) ____________________________________________
Type of switch: The following switches have been tried: (Check all that apply)
Plate
Wobble
Rocker
Joystick
Eyebrow
Sip/Puff
Flex
Mercury (tilt)
Other: ____________________________________
Summary of student’s abilities and concerns related to computer/device access:
____________________________________________________________________
____________________________________________________________________
Region One VI/Assistive Technology Project (2001)
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Communication
Student’s present means of communication: (Check all that apply)
Changes in breathing patterns
Body position changes
Eye-gaze/eye movement
Facial Expressions
Gestures
Pointing
Sign language approximations
Sign language (# signs ____)
Vocalizations, examples ________________
Single words, examples _________________
Yes/No
2 –3 words Examples _________________
Intelligible Speech ___________________
Unintelligible Speech _________________
Communication board (# of symbols____________) See comment on page 10
Voice Output Device (Name of device ________________ # symbols ________)
Writing
Current level of receptive language ______________________________________
Current level of expressive language _____________________________________
Summary of student’s abilities and concerns related to communication:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Mechanics of Writing
Current writing ability: (Check all that apply)
Uses regular pencil
Can copy words
Uses adapted pencil
Can copy from board
Can print name
Uses regular paper
Can print a few words
Uses special paper (Example _________)
Can write cursive
Writes independently and legibly
Fatigues easily when writing
Uses Perkins brailler
Writing is slow
Region One VI/Assistive Technology Project (2001)
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Current keyboarding ability: (Check all that apply)
Does not type
Uses portable word processor for typing
Types with one finger
Requires wrist or hand support to write
Uses adapted keyboard to type ( Name ___________________)
Can perform 10 finger typing (wpm ____________________)
Uses switch for typing ( Name ______________________)
Uses adapted software ( Name ______________________)
Summary of student’s ability and concerns related to writing: _______________
____________________________________________________________________
____________________________________________________________________
Written Composition
Student’s present writing is: (Check all that apply)
Single words
Paragraphs
Phrases
Essays
Sentences
Student has difficulty with: (Check all that apply)
Getting started on a sentence or story
Using a variety of vocabulary
Generating ideas
Summarizing information
Adding information to a topic
Planning content
Sequencing information
Aids or assistive technology currently used: (Check all that apply)
Word cards/books
Word Processing Software
Word Wall
Talking Word Processing Software
Dictionary
Abbreviation/Expansion Software
Electronic dictionary
Word Processing with Word Prediction
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Talking dictionary
Multimedia Software
Symbol based software
Voice Recognition Software
Portable word processor
Summary of student’s abilities and concerns related to composing written material:
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Reading
Student reads at ___________ grade level orally.
Student reads at ___________ grade level silently.
Aids or assistive technology currently used: (Check all that apply)
Smaller amount of text on paper
Highlighting
Enlarged text
Talking Dictionary
Lowered reading level
Electronic books
Audio tapes
Books on computer
Reduced length of assignment
Computer with talking word processor
Colored filters
Computerized reading system
Typoscope
Summary of student’s abilities and concerns related to reading: _____________
____________________________________________________________________
____________________________________________________________________
Study Skills
Student has difficulties in: (Check all that apply)
Remembering assignments
Remembering steps of assignments/tasks
Taking notes during lecture
Reviewing lecture notes
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Organizing notes
Turning in assignments
Aids or assistive technology currently being used: ( Check all that apply)
Print schedule
Palm computers
Low tech aids to find materials (Example _______________________)
Highlighting
Voice output reminders
Software for manipulation of objects and concepts
Organizational software
Summary of student’s abilities and concerns in the area of learning and studying:
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
Math
Student has difficulty with: (Check all that apply)
Legibly writing numbers
Understanding math vocabulary
Understanding meaning of numbers
Understanding place value
Understanding simple math facts
Understanding measurement
Solving story problems
Graphing
Aids or assistive technology currently being used: (Check all that apply)
Abacus
Computer calculator
Math line
Scanning calculator
Enlarged worksheet
Alternate keyboards
Money calculator/Coinulator
Math worksheet software
Tactile/Voice measurement devices
Software for manipulation of objects
Calculator
Talking calculator
Summary of student’s abilities and concerns related to math:
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_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
General Information
1. Are there any behaviors (positive and negative) that significantly impact the
student’s performance?
_________________________________________________________________
_________________________________________________________________
2. Are there any other factors about the student that the assistive technology
team should consider?
________________________________________________________________
________________________________________________________________
***** Please attach a copy of the student’s communication boards if that area has
been checked in the communication section.*****
Campus should plan to have the student folder available for reviewing
prior to the assessment. The folder will be reviewed upon arrival at the
campus, so time will need to be allowed for this function.
Region One VI/Assistive Technology Project (2001)
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Region One VI/Assistive Technology Project (2001)
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