Assistive Technology
Assessment report and application form
Examples of completed applications are available here:
www.education.govt.nz.
If you are applying for an FM system for a student with
Auditory Processing Disorder, vision equipment or furniture,
please contact the District Technology Coordinator at your local
Ministry of Education office.
01
Applications should be submitted by the first Tuesday in of
each month to be considered for subsequent moderation
meetings. Urgent applications may be considered on a case
by case basis.
Please save this form before use.
Student information
Student name:
Date of birth:
Date of application:
Age:
School year level:
Ethnic group/s:
School name:
School telephone:
Facility number:
School email:
Assessor details (team member completing this form):
Name:
Assessor's role:
Assessor Telephone:
Assessor email:
List names of other team members and their roles (e.g. student, parents, teacher, support staff etc):
Team member responsible for 6 month review:
Name
02
Email:
Eligibility
1. Click here for options If using SEG, detail the number of hours and type of learning support (see Eligibility
www.education.govt.nz for SEG eligibility criteria):
2. In classes where most students have a device such as a laptop or tablet, applications for those devices through
assistive technology will not be considered because they are typical classroom equipment.
I confirm that this is not typical classroom equipment:
.
3. Under the protocols between Education, Health and ACC, funding responsibility lies with Education: Yes
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Student information relevant to this application
1. Explain the student’s learning needs that have led to this application - include current diagnosis if any (max 8 lines):
2. What curriculum level does the student mostly work at? *: Click to select Use level for subject most relevant to this
application if unsure.
3. Do you expect this student to move to another school/leave school within the next year? Click for options. If yes
please refer to footnote† and provide details:
04
Learning environments
1. Type of technology used in the school (Mac/Windows/Tablet or iPad/Mixed etc):
2. What technology is available in the student’s classroom (relevant to this application):
3. How much access does this student have to the classroom technology?
4. What proportion of the students in this class have their own dedicated technology (such as laptop/tablet):
5. Allocated hours of additional teacher/teacher aide support per week:
6. Other relevant school information (max 4 lines):
05
Key learning goals (based on NZ Curriculum/IEP)
1. What are the key learning goals relevant to this application for assistive technology? (please list a maximum of 3):

06
Technology currently allocated to student (or privately funded for their exclusive use)
1. What dedicated technology does the student currently have? (please list):

2. How is the current technology used?

*
If the student overlaps two levels state the lower of the two. If the student works across multiple levels state the level for reading and writing literacy.
Level 1 is the lowest curriculum level so no pre level 1 exists.
†
Applications should be completed well before transition or should be done after the transition to ensure compatibility in the new school environment.
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New assistive technology considered
1. List the key features of the technology that the student needs to support their learning:
2. Based on these characteristics, list the technology and/or software chosen for trial:
3. What other options were considered and why were they rejected? (please list a maximum of 5 options with short
notes):

4. Have you consulted the school’s IT personnel regarding the technology options within the school context?
(Yes/No)
. If no please give reasons:
5. If successful, how often will the technology be used? Click for options
08
Requested technology - trial results
Attach two work samples or photos if appropriate – one without and one with the assistive technology. Samples
should show the difference the assistive technology makes to learning outcomes (include date and short description of
analysed sample on each page). See examples of completed applications at http://www.education.govt.nz
Trial analysis:
Pre trial
Post trial
Tool used
e.g. pen/paper etc or technology the
student already has.
Hardware:
Trial goal (based on
learning goals in
section 5)
Software:
Length of trial:
Ensure you include the following information:
 how they use the tool to do the task
 what support was required
 on task behaviour
For each trial goal provide:
 qualitative and quantitative evidence for learning outcomes - see appendix 1
Trial goal
Select from appendix 1
or write your own
Trial goal
Select from appendix 1
or write your own
Trial goal
Select from appendix 1
or write your own
Other comments from trial (max 5 lines):
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ASSISTIVE TECHNOLOGY – Supporting Students with Special Needs
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Cost and rationale of requested assistive technology
List each item and attach a copy of the preferred quote. If this is not a cost effective solution or if there is insufficient
rationale for the specific make and model, the application will be deferred and an alternative quote will be requested.
Supplier name and
quote number if
supplied
Technology - list and
price each item
separately).
Rationale for items not clearly detailed in
trial table (e.g. carry bag, head phones and
specific make/model)
See note re apps‡
Cost (excl.
GST) GST
calculator
TOTAL
(incl. GST)
Freight (detail each
if more than one)
TOTAL
10
Further training
If applicable, outline further training needs based on educational outcomes. Attach a detailed training plan if you are
applying for funding for this training as part of this application.
11
Managing the assistive technology
Outline how the assistive technology would be cared for (click to use drop down menus for relevant information):
Ongoing maintenance:
Portable devices:
Homework:
Other management:
‡
Click here for options
Click here for options
Click here for options
Only list apps that were trialled and trial results show they are essential to address specific learning needs.
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Acceptance of responsibility - parent/caregiver to complete
I/we understand and accept that we are responsible for:
1.
2.
3.
4.
Following the agreed management plan for the assistive technology where applicable.
Notifying the school if the assistive technology is no longer meeting the needs of the student.
Keeping the equipment clean and well looked after.
Returning the assistive technology to the school if the equipment needs repairing or if it is no longer being used for
the intended purpose by the student it is allocated for.
I/we understand and accept the responsibilities above and agree to the following privacy statement:
Privacy: The personal information on this form is being collected for the purpose of allocating equipment and will be
reviewed by teams from the Ministry of Education. The information will not be used or disclosed for any other purpose
except in accordance with the Privacy Act 1993. The information collected will be held by the Ministry of Education.
Students have the right under the Privacy Act to request access to and correction of their personal information.
Parent/Caregiver name:
Relationship to student:
Home address:
Home phone:
Signed (Parent/Caregiver):
13
Date:
Acceptance of responsibility - principal to complete
Please note the following processes and conditions must be followed. You accept that the school:
1. Will assume ownership of the assistive technology for the time that the student is enrolled in the school, including
listing the technology on the school’s asset register, and maintaining a record of the serial numbers and asset
numbers or other descriptions of the approved technology along with supplier details and warranty conditions.
2. Will arrange to buy the assistive technology in line with the approved application (details in quote - section 10) if
required.
3. Will ensure that the assistive technology is used for the intended purpose by the student it is allocated for.
4. Is responsible for the safekeeping of all assistive technology items such as original software, manuals and
accessories etc. as documented in the management plan.
5. Is responsible for insuring the assistive technology and will contact the local Ministry of Education office if repair,
maintenance or replacement of the item is needed§.
6. Will support the implementation and ongoing use of the assistive technology within the school including the agreed
training plan if applicable.
7. Will load appropriate school software and use appropriate school technology to support the student such as generic
programs like Microsoft Office, virus software and access to school networks.
8. Will notify the local Ministry of Education office when the named student transfers to another institution or leaves
school, and will transfer the assistive technology to the new school (with the student) or return it to the Ministry of
Education.
9. Agrees that the scanned version of this document can act as the record copy for this application.
Principal name:
School:
Signed (Principal):
Date:
§
For more information on the Ministry of Education and school responsibilities in case of loss, damage or replacement, please see the Insurance and
Repairs Fact Sheet (www.education.govt.nz) – assistive technology).
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Checklist
All signatures are completed
Trial results include qualitative and quantitative evidence of significantly improved educational outcomes
Attached pre and post trial work samples (for example writing samples where the key issues relate to writing)
Preferred quote is attached and is cost effective
Peer review is completed and signed OR
the assessor has already completed two applications
Include only if appropriate to support this application:
Detailed training plan, if appropriate
Photos if appropriate (especially to show complex technology set-ups such as switch systems)
15
Peer review
Peer review is recommended in all cases. For the first two applications this section is compulsory.
Name of peer reviewer:
Position:
Signature:
16
Date:
Assessor
Signed (assessor):
17
__________________________________________ Date:
Recipients of this report
Team as per page 1
Other recipients:
Please email the completed application form, with supplier’s quote and work samples to the District Technology
Coordinator at your local Ministry of Education office.
The final dates for all assessors wanting to submit applications are the first Tuesday of each month. Urgent
applications may be considered on a case by case basis so please contact us if you have special circumstances.
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ASSISTIVE TECHNOLOGY – Supporting Students with Special Needs
Appendix 1: Collecting quantifiable evidence for trial goals
Trial Goal
Measure
Quantifiable Measurements:
Take a timed writing sample and analyse written work using the suggested
measures below. Observe and document learning behaviours. (Photos may
be appropriate).
To be able to produce
written work (when
student cannot hold or use
a pen/pencil)
To increase legibility of
written work
Ability to produce
written work
Observe and document
The barriers to writing without the use of technology e.g. unable to grasp a pencil;
fine motor difficulties which prevent use of pen/pencil.
Ability to write with technology.
Legibility
% of letters correctly formed
% of letters or words that can be deciphered
Spacing of letters/words on a line or page
Fatigue – how does it affect legibility and at what point in time does this occur e.g.
after 5 minutes of writing or more?
Can the writing be read back by the student or another person?
To increase readability or
quality of written work
Number of spelling,
punctuation or
grammatical errors
% of words spelt correctly
% of correctly used punctuation
Number of correctly structured sentences
Use of vocabulary – simple/advanced.
Standard of writing - compared to expected level for age/curriculum level (use writing
exemplars)
Can the writing be read back by the student or another person?
To increase quantity of
written work produced
within a specific time span
e.g. classroom writing
session
Word count or number
of sentences/
paragraphs
Use a realistic time measure for the student e.g. 20-30 min writing session
Calculate rate – e.g. Words per minute/10 minutes/20 minutes
Number of sentences/number of words within sentence?
Number of paragraphs/ number of sentences within paragraphs?
How does this compare with expectations for age?
How does this compare with oral/cognitive ability to recount information?
Does the student complain of fatigue or pain in the hand when writing, which limits
their output? How long can they write before this occurs?
To increase ability to
complete a set task within
a specific time span
Complete a set task
Document ability to complete learning tasks within expected class time frames e.g.
complete a written recount; complete a set of comprehension questions; complete
basic facts learning task; research topic information etc.
To increase independence
in producing written work
and/or completing work
Independence/
Observe and document behaviour and support
level of support
Can the student get started on the learning activity without prompting?
How long do they take to get started?
Can the student complete the activity without assistance?
Does the student need 1:1 support to stay on task?
How many times would a teacher or teacher aide need to prompt the student (in a
timed session)? E.g. prompt 10 times in 20 minutes.
Does the student need a scribe to take down high order ideas?
To increase engagement
in the learning tasks
On task behaviour
Observe and document behaviour
Is the student willing to engage in the activity and stay on task?
% of time they stay on task before losing interest?
Do they exhibit avoidance behaviours?
Frequency and type of avoidance behaviours in a timed session?
To increase ability to
independently access
learning activities (that
would otherwise need 1:1
support)
Independent access to
learning activities
Observe and record the student’s ability to choose and complete a variety of learning
activities within class.
With technology support is the student able to work independently, or work with less
support, on tasks that would otherwise need to be set up by the teacher/aide and
need 1:1 support?
For example, read a book or access reading material above their reading age (using ereaders, text-to-speech); recount a story (using support software/applications); and/or
complete numeracy activities. Multimedia resources such as speech recording; images
– including photo/video can be used as an alternative to traditional text resources.
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