WISD 1/05
WISD Assistive Technology Decision-Making Process
Form 1: Beginning the Process
Student Name:
Birthdate:
School:
IEP Eligibility:
Date of Referral:
Age:
District:
Referring person:
Grade/Placement:
Team Members: Please identify all team members involved with this student.
Check names of those who will serve on the AT team.
Name:
Phone/Email:
Case Manager
Parent/Guardian
Teacher Consultant
Teacher Assistant
OT
PT
SLP
Psychologist
Social worker
Administrator
AT Consultant
Others
Pertinent Medical/Physical Considerations:
Health Problems
Fine motor
Seizures
Hand/arm use
Fatigue/Attention
Other:
Hearing
Vision
Behavior
Referral Question: What task(s) does the student need to do that is currently difficult or
impossible, and for which assistive technology may be an option?
Based on the referral question, select areas of concern and check all areas that apply.
Motor Aspects of Writing
Recreation and Leisure
Fine Motor Related to Keyboarding, Computer or Device Access
Seating and Positioning
Composing Written Material
Mobility
Communication
Vision
Reading
Hearing
Learning and Studying
Environmental
Math
Other
Refer to the AT Guide for optional assessment tools for these areas if more information is needed.
Send copies of this form to:
Building Principal/Supervisor
Identified AT Team Members
Special Ed Director
Special Ed file/ca 60
Other
Date Sent
By:
Adapted from WATI Assessment Package (2004)
WISD 1/05
FORM 2:
Problem Identification and Solution Generation
WISD Assistive Technology Decision-Making Process
Student:
Date:
AT Contact Person:
AT Team members present:
Referral Question: What task(s) does the student need to do that is currently difficult or impossible, and for which assistive technology may be
an option?
Student
What specific parts of
What is the student’s
this task are difficult for
present level regarding
the student?
this task?
Environment
Environmental
Considerations
Tasks
What are the taskspecific outcomes for the
student and what data
would show
achievement? Star (*)
according to priority.
Refer to the AT Guide for optional assessment tools if more information is needed.
Adapted from WATI Assessment Package (2004)
What has already been
tried? What was the
outcome?
Tools
Brainstorm possible
solutions for the priority
outcomes. Star (*)
solutions to be tried first.
WISD 1/05
FORM 3:
Trial and Follow-Up Plan
WISD Assistive Technology Decision-Making Process
Student:
Date:
AT Contact Person:
AT Team members present:
Referral Question: What task(s) does the student need to do that is currently difficult or impossible, and for which assistive technology may be
an option?
TASKS
Task-specific
Outcome(s) Being
Addressed
WHAT
What AT will you try?
How and where will you try it?
HOW
How will you:
*Acquire the AT
*Provide training
*Collect data
Refer to AT Guide for Optional Data Collection Tools
Adapted from WATI Assessment Package (2004)
WHO
Who will :
*Acquire the AT
*Provide training
*Collect data
WHEN
Dates for:
*Trial
periods
*Follow-up
meetings
FOLLOW UP
Expected Outcome
Next Steps
*Criteria Met?
e.g. Recommendation for
(Show supporting
IEP, other AT to be tried,
data.)
comments
FORM 4: AT Notes
WISD Assistive Technology Decision-Making Process
Student:
Date
Notes
By: