July 23, 2012
Assistive Technology
Process
Table of Contents IU1 Assistive Technology Process
IU1 Assistive Technology Decision-Making Tree………………………………….. 6
IU1 Assistive Technology Options
Option A ................................................................................................ 7
Option B ................................................................................................ 8
Option C ................................................................................................ 8
Frequently Asked Questions - FAQs ................................................... 10
AT & the IEP ........................................................................................ 10
AT Recommendations ......................................................................... 11
AT Services & Settings ......................................................................... 12
AT Consultation Follow-up .................................................................. 12
AT Funding…………………………………………………………………………………… 12
AT School-Age & Early Intervention Services…………………………………. 13
IU1 Assistive Technology Considerations Checklists............................... 14
AT Intervention for Communication ................................................... 14
AT Intervention for Computer Access ................................................. 14
AT Intervention for Mathematics ....................................................... 15
AT Intervention for Organization ........................................................ 15
AT Intervention for Reading ................................................................ 15
AT Intervention for Seating and Positioning ....................................... 16
AT Intervention for Sensory Needs ..................................................... 16
AT Intervention for Writing............................................................. - 17 IU1 Request for Assistive Technology Consultation ........................... - 19 The SETT Framework - Part 1, Collaborative Consideration of Student
Need for Assistive Technology Devices and Services………………………… 42
The SETT Framework – Part II, Incorporating AT into School Tasks ....... 44
Assistive Technology Trial Period Plan and Rating Scale ........................ 45
Assistive Technology Roles and Responsibilities Matrix ......................... 46
IU1 Assistive Technology Process
PLEASE NOTE THE FOLLOWING CHANGES THAT GO INTO EFFECT AT THE BEGINNING OF THE 2012-2013
SCHOOL YEAR
1. This document contains all necessary information to assist in determining assistive technology for a
student – whether facilitated by the IU1 Assistive Technology Consultants or conducted by an individual
student’s IEP team.
2. Teams make a decision as to whether the services of the Assistive Technology Consultant are required.
Three options are offered and highlight the specific forms that must be completed for the desired level of
service.
a. Option A – The team requires assistance from the IU1 AT Consultant to identify AT for IEP/program
planning purposes. The following options for assistance are available:
1) Pre-Referral Screening
i. The LEA/designee will notify the parents of the screening request for a particular
area(s) (See REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form).
ii. The LEA/designee sends REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form and
any appropriate intake forms to the Assistive Technology (AT) secretary.
iii. Upon receipt of the REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form, the AT
secretary will stamp and date, and distribute to the Assistive Technology (AT)
Consultant.
iv. The AT Consultant will schedule the screening, which will consist of an observation of
the student.
v. Prior to the screening, the AT Consultant will review the intake forms.
vi. The AT Consultant will make recommendations for consideration to the student’s
school-based team.
vii. The school-based team will receive a summary report within 4 weeks from the date of
the screening.
2) Evaluation
i. The LEA/designee will send a copy of the signed Permission to Evaluate and the
REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form along with the appropriate
intake forms and any other pertinent information is sent to the AT Secretary.
ii. Upon receipt of the REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form, the AT
secretary will stamp and date, and distribute to the AT Consultant.
iii. The AT Consultant will complete the evaluation and will submit a report to the IEP
team for consideration and possible inclusion in the student’s Evaluation Report (ER).
The report will make recommendations as to the student’s need for assistive
technology in order to access his/her general education curriculum.
iv. The student’s IEP team will consider the recommendation of the AT evaluation when
developing the IEP. If needed, “assistive technology” will be checked under the
“special considerations” section of the IEP and will then be reflected as specially
designed instruction, supplemental aids and services, program modifications,
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supports for school personnel and/or incorporated into the student’s IEP
goals/objectives.
3) Re-evaluation
i. The IEP team must meet and determine that there is a need for additional data and
complete the Reevaluation Report (RR) and issue the Permission to Reevaluate
Consent form.
ii. The LEA/designee will send the REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form
along with the signed Permission to Reevaluate Consent form, RR and current IEP to
the AT secretary.
iii. The AT Consultant will complete the evaluation and will submit a report to the IEP
team in order to complete the “DETERMINATION OF NEED FOR ADDITIONAL DATA,
SUMMARY AND CONCLUSIONS” of the RR. The report will make recommendations as
to the student’s need for assistive technology in order to access his/her general
education curriculum.
iv. The student’s IEP team will consider the recommendations of the AT evaluation when
developing the IEP. If needed, “assistive technology” will be checked under the
“special considerations” section of the IEP and will then be reflected as specially
designed instruction, supplemental aids and services, program modifications,
supports for school personnel and/or incorporated into the student’s IEP
goals/objectives.
4) Consultation
i. The LEA/designee will notify the parents of the consultation request for a particular
area(s) (See REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form).
ii. The LEA/designee sends REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form and
any appropriate intake forms to the AT secretary.
iii. Upon receipt of the REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES form, the AT
secretary will stamp and date, and distribute to the Assistive Technology Consultant.
iv. The Assistive Technology Consultant will schedule the consultation that consists of
observation, one-on-one work with the student, and team meeting.
v. The LEA will designate at least two team members to meet with the Assistive
Technology Consultant to discuss recommendations and draft an action plan following
the consultation, based on the Student Environment Task Tools (SETT) Framework,
refer to FAQ on page 10. It is the school’s responsibility to share recommendations
with parents if they are not participating in the meeting.
b. Option B – The team has a clear idea of which assistive technology should be trialed or implemented.
Assistance is needed in acquiring loans or learning about product features. An onsite consultation is
not conducted; a team meeting or communication with the Assistive Technology Consultant may be
useful. Request for Short Term Loan is to be initiated by member of the IEP Team and processed by
IU1.
1) The IEP team documents the specific tasks and environments for which assistive technology is
being considered for an individual student.
2) The IEP team specifies the specific tools that need to be acquired for trial or training purposes.
3) The IEP team defines the roles and responsibilities of team members who then coordinate loan
and training needs with the Assistive Technology Consultant.
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o
Option C – The team does not require the services of the IU1 AT Consultant; however, the team wants
to document information in preparation for IEP planning or program development. An onsite
consultation is not conducted, a team meeting with the Assistive Technology Consultant is not
necessary. Instead, the team may opt to use portions of the IU1 assistive technology form for recordkeeping and data collection purposes, i.e. SETT Framework, Data Collection Forms, etc.
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IU1 Assistive Technology Decision-Making Tree
Is assistive techology needed
NO
Check “No” under Section I
(page 4) of the IEP: “Special
Considerations the IEP Team
Must Consider Before
Developing the IEP”
YES
YES
Does the team have sufficient
assistive technology data to
develop the IEP?
NO
Follow directions to Option A
The team requires assistance
from the IU 1 Consultant to
identify AT for IEP/Program
planning purposes.
Does the team require assistance
from the IU AT Consultant?
NO
YES
NO
Does the team have sufficient
assistive technology data to
develop the IEP?
YES
Follow directions for Option B
Follow Directions for Option C
Develop IEP as appropriate.
The team has a clear idea of
which assistive technology
should be trialed or
implemented. Assistance is
needed in acquiring loans or
learning about product features.
The team does not require the
services of the IU 1 AT
Consultant; however, the team
wants to document information
in preparation for IEP planning
or program development using
the SETT Framework and data
collection forms.
Check “Yes” under Section 1
(page 4) of the IEP: “Special
Considerations for Assistive
Technology, Present Education
Levels, Goals & Objectives
SDI’s, etc.
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IU1 Assistive Technology Options
Option A
The team requires assistance from the IU1 AT Consultant to identify AT for IEP/program planning purposes.
1. Team completes Referral For Assistive Technology Services (p. 18) and forwards to district administrator/LEA for approval.
2. Administrator/LEA approves request.
3. Request and required documentation is sent to IU1 AT Program.
4. Request is confirmed, Parent/Teacher In-Take Forms sent out, and pre-referral screening, evaluation/reevaluation, or consultation is scheduled.
a. If a pre-referral screening is requested, the AT consultation will complete an observation of the student. Prior to the screening, the AT Consultant
will review the intake forms. The AT Consultant will make recommendations for consideration to the student’s school-based team. The schoolbased team will receive a summary report within 4 weeks from the date of the screening.
b. If an evaluation is requested, the AT Consultant will complete the evaluation and will submit a report to the IEP team for consideration and
possible inclusion in the student’s Evaluation Report (ER). The report will make recommendations as to the student’s need for assistive technology
in order to access his/her general education curriculum. The student’s IEP team will consider the recommendation of the AT evaluation when
developing the IEP.
c. If a reevaluation is requested, the AT Consultant will complete the evaluation and will submit a report to the IEP team in order to complete the
“DETERMINATION OF NEED FOR ADDITIONAL DATA, SUMMARY AND CONCLUSIONS” of the RR. The report will make recommendations as to the
student’s need for assistive technology in order to access his/her general education curriculum. The student’s IEP team will consider the
recommendations of the AT evaluation when developing the IEP.
d. If a consultation is requested, a follow-up team meeting to complete the SETT Framework documents (outlined below) and discuss a plan of action
will be conducted following the completion of the one-on-one work with the student. The SETT Framework – Part I, Collaborative Consideration of
Student Need for Assistive Technology Devices and Services form (p.39)*
1) The SETT Framework – Part II, Incorporating AT Into School Tasks form (p. 41)*
2) Assistive Technology Trial Period Plan and Rating Scale form (p. 42)*
3) Assistive Technology Roles and Responsibilities Matrix form (p. 43)*
5. AT Consultant will follow-up, if requested, to assist in implementing/programming of short-term loan device(s).
6. AT trainings are scheduled and conducted as needed.
7. IEP team meets to review outcomes of trials and/or recommendations are discussed via *aforementioned documentation.
8. AT Consultants will attend any follow up meetings IF requested by IEP Team.
9. Student’s IEP is revised or developed as appropriate.
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a.
b.
c.
d.
If needed, “assistive technology” will be checked under the “special considerations” section of the IEP.
Use general terminology in Section IV, Part A—Program Modifications and Specially Designed Instruction (SDI) of the IEP.
If necessary, document training needs of staff under Section VI, Part C—Supports for School Personnel.
If needed, assistive technology will be incorporated into the student’s IEP goals/objectives.
Option B
The team has a clear idea of which assistive technology should be trialed or implemented. Assistance is needed in acquiring loans or learning about
product features.
1. District IEP Team completes the following forms and submits them to the IU1 AT Program:
a. The SETT Framework – Part II, Incorporating AT Into School Tasks form (p. 41)
b. Assistive Technology Roles and Responsibilities Matrix form (p. 43)
2. Trials of devices or software may be accessed via the following and processed by IU1 (as requested by district):
a. Loaner equipment from the PaTTAN short-term program (www.pattan.net/supportingstudents/shorttermloan.aspx)
b. Pennsylvania Initiative on Assistive Technology (PIAT) AT Lending Library (www.disabilities.temple.edu/programs/assistive/atlend/)
c. Demo software, loans or rental from AT Vendors
3. Equipment trials and training are conducted as needed—Team completes AT Trial Period Plan and Rating Scale.
4. IEP team meets to review outcomes of trials and/or recommendations.
5. Student’s IEP is revised or developed, as appropriate.
a. Use general terminology in Section IV, Part A—Program Modifications and Specially Designed Instruction (SDI) of the IEP.
b. If necessary, document training needs of staff under Section VI, Part C—Supports for School Personnel.
Option C
The team does not require the services of the IU1 AT Consultant; however, the team wants to document information in preparation for IEP planning or
program development.
1. Team MAY complete the assistive technology forms to use within their own team planning process. No information needs to be submitted to the IU1
AT Consultant.
a. Assistive Technology Intake Form (p. 19)
b. Parent Intake Form (p.26)
c. The SETT Framework – Part I, Collaborative Consideration of Student Need for Assistive Technology Devices and Services form (p. 39)
d. The SETT Framework – Part II, Incorporating AT Into School Tasks form (p. 41)
e. Assistive Technology Trial Period Plan and Rating Scale form (p. 42)
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f. Assistive Technology Roles and Responsibilities Matrix form (p. 43)
2. Trials of devices or software may be accessed via:
a. Loaner equipment from the PaTTAN short-term program (www.pattan.net/supportingstudents/shorttermloan.aspx)
b. Pennsylvania Initiative on Assistive Technology (PIAT) AT Lending Library (www.disabilities.temple.edu/programs/assistive/atlend/)
c. Demo software, loans or rental from AT Vendors
d. District-owned devices/software
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Frequently Asked Questions – FAQs
Assistive Technology (AT)
What is an Assistive Technology Device?
Definition: An Assistive Technology device means any item, piece of equipment, or product system, whether
acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve
the functional capabilities of a child with a disability. The term does not mean a medical device that is
surgically implanted, or the replacement of such device (34 CFR 300.5).
What are Assistive Technology Services?
Definition: Assistive technology service means any service that directly assists a child with a disability in the
selection, acquisition, or use of an assistive technology device (34 CFR 300.6).
AT Services may include:
• Evaluation of AT needs
• Purchasing, leasing, or providing for acquisition of AT
• Selecting, designing, fitting, customizing, or adapting AT devices
• Coordinating and using other therapies, interventions, or services with AT devices
• Training or technical assistance in use or operation of AT for child, family, or team member
Assistive technology services are those that are necessary to enable the student and/or IEP team to use any
AT devices specified in the IEP.
AT & the IEP
Are there prerequisite student skills that must be met in order for a team to consider assistive technology?
There are no prerequisite skill sets that are necessary for a student to be considered for assistive
technology and students do not “qualify” for assistive technology devices or services. Decisions to implement
assistive technology are based upon observable needs and the potential for a particular tool or strategy to
meet those needs. The IEP team considers assistive technology as part of the multidisciplinary evaluation
process and through formative assessment that is inherent in high-quality instructional practice. Failure at
tasks or mastery of certain academic, communicative, or technology skills (e.g., use of low-tech tools before
high-tech ones are considered) should not be used as artificial prerequisites for exploring solutions along the
assistive technology spectrum.
When should assistive technology devices or services be considered by the team? Is a child too young or too
old for assistive technology?
It is never too soon or too late to consider using assistive technology. Here are some suggestions for when
to consider assistive technology use:
 When disability limits an individual’s ability to play, communicate, and interact with the environment
 When disability interferes with experiential learning and exploration
 When a significant gap exists between an individual’s receptive and expressive language abilities (i.e., an
individual has the ability to understand more receptively than he/she can communicate expressively)
 When a significant performance gap appears between an individual and his or her peers
 When a physical disability is impeding the potential of an individual
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 When a disability is limiting an individual’s level of independence
Source: http://www.believeability.com/faq.html
Is an assistive technology consultation required for AT to be considered, identified, or implemented by an
IEP team?
No. Assistive technology must be considered as part of Section I of a student’s IEP; but, there is no
requirement for a team to utilize services of an AT Consultant in order to fulfill the requirement of IDEA. In
cases where school districts have the local capacity to adequately address a child’s AT needs, the services of
the AT Consultant may be redundant.
The IEP team has determined that an assistive technology consultation is necessary to help plan a child’s
IEP. Is Permission to Evaluate/Reevaluate required for an assistive technology consultation?
No. Evaluations are conducted by the student’s Local Education Agency (LEA) and may include assistive
technology as one portion of the overall evaluation or reevaluation. Any evaluation of assistive technology
would span the course of several weeks and occur in the student’s natural environments. The services
provided by the IU1 Assistive Technology Consultants are consultative in nature, however, and do not
constitute an evaluation. As a result, the Permission to Evaluate/Reevaluate is not required or recommended
to receive the consultation services of the AT Consultant.
Who determines what assistive technology is appropriate and necessary?
Assistive technology determinations are the sole responsibility of the IEP team as a result of data
collection and review. Determinations are not made by the IU1 Assistive Technology Consultant.
What assessment tool can be used when determining assistive technology recommendations?
The IU1 AT Consultants use the SETT Framework to guide the Assistive Technology Process. The SETT
framework is a guideline for gathering data to make effective AT decisions. The SETT Framework considers
first, the STUDENT, the ENVIRONMENT(S) and the TASKS required for active participation in the activities of
the environment, and finally, the system of TOOLS needed for the student to address the tasks.
Retrieved April 24, 2012, from http://www2.edc.org/ncip/workshops/sett/SETT_Framework.html
Once a decision is made to implement assistive technology, what should be written into the IEP?
Assistive technology should be listed in Section VI, Part A of the student’s IEP--Program Modifications and
Specially Designed Instruction (SDI). Teams should utilize generic terminology rather than specific product
names when writing a student’s IEP. Examples of generic terminology can be found in the Assistive Technology
Considerations Checklists (p.11). This allows the team to clarify the essential features of the assistive
technology that are required to ensure access to a free and appropriate public education (FAPE) rather than
naming specific products that may or may not remain on the market for the duration of the IEP.
AT Recommendations
Why are there sometimes so many recommendations offered by the Assistive Technology Consultant?
Students encounter a wide variety of tasks, environments, and people throughout the span of their
academic year. The interplay of these varied components (and effective instruction) often requires the artful
use of a wide variety of no-tech, low-tech, and high-tech tools. Recommendations by the AT Consultant are
intended to convey the range of tools that a team should consider, but are in way comprehensive. When hightech options are recommended, in particular, it is also necessary to plan for no-tech and low-tech alternatives
to ensure that FAPE can be ensured in the event of device failure or repair.
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AT Services & Settings
A student is receiving services under a Section 504 Service Agreement rather than an IEP. Is assistive
technology available for such a student?
Assistive technology services provided by Intermediate Unit 1 are provided under the mandate of the
Individuals with Disabilities Education Act (IDEA) and are provided to the Local Education Agency (LEA) serving
students for whom an IEP is in effect or being considered. Assistive technology, however, is an important
component of other federal and state legislation, such as Section 504 of the Americans with Disabilities Act
(ADA). As a courtesy to local school districts, the IU1 Assistive Technology Consultant can provide support to
districts implementing Section 504 Service Agreements. LEAs should utilize the same process to access those
services as they would for a student protected under IDEA.
Can parents or students access the services of the IU1 Assistive Technology Consultant directly?
The Individuals with Disabilities Education Act (IDEA) is the authority under which the Intermediate Unit 1
provides services to Local Education Agencies (LEAs). As a result, consultative services are not provided
directly to a family or individual, but are initiated solely at the request of the LEA. Accordingly, any
recommendations or services by the Assistive Technology Consultant are provided through the LEA. It is the
responsibility of the LEA to maintain communication with the family and other relevant team members.
What services are provided under the domain of assistive technology?
IU1 provides consultative services in assistive technology that include providing information to teams
about current technologies, training team members on the AT, participating in meetings and discussions that
focus on AT implementation for students, making AT recommendations to IEP teams, and facilitating loans
when AT devices or software are available to those purposes.
In what settings are assistive technology devices to be provided?
The IEP team makes the determination as to which settings require assistive technology in order to
provide a free and appropriate public education (FAPE). These settings may include locations such as the
school building, a community setting, a workplace, and/or the student’s residence.
AT Consultation Follow-up
What is the process if our team has follow-up questions or training needs relating to a student who was
previously seen by the AT Consultant?
Contact the AT Consultant who conducted the initial consultation. This information is indicated on the AT
Action Plan that was generated as a result of the initial consultation. In most cases, a conversation, email
exchange, or follow-up visit will be sufficient to meet the team’s needs. In situations where the characteristics
of the student and/or program have changed considerably, the AT Consultant may direct the team to submit a
new Request for AT Consultation.
AT Funding
Who funds assistive technology devices and services that are recommended?
Assistive technology devices that are deemed necessary to prove a free and appropriate public education
(FAPE) are written into a student’s IEP. Assistive technology is, therefore, a responsibility of the Local
Education Agency (LEA).
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What are the requirements of a school district in cases where a student is using family-provided technology?
The Local Education Agency (LEA) is responsible for maintaining assistive technology that is part of the IEP,
including devices that may have been funded through Medical Access, private insurance, or family purchase.
While a variety of funding options may be considered by a team, the ultimate responsibility to provide FAPE
lies with the LEA.
AT School-Age & Early Intervention Services
How is assistive technology handled for transitions – either transitions from early intervention to school-age
or school-age to postsecondary education?
Decisions relating to transition and assistive technology are primarily determined by the method in which
a particular assistive technology tool was funded and, secondarily, by policies of the Local Education Agency
(LEA). It is in the best interest of the student, LEA, and other agencies to discuss expected transitions as part of
the regular planning process so that transitions can occur with minimal or no disruption of needed technology.
 If assistive technology was purchased with District Access funds, but a Transfer of Ownership was issued;
the technology is the property of the student and therefore moves with the student at transition.
 If assistive technology was purchased with District Access funds but ownership was retained by the LEA
(i.e., a Transfer of Ownership was not issued), the LEA makes the determination whether to send the
assistive technology to the new placement or to retain the assistive technology for use by other students.
o In situations where a student transitions from early intervention to school age (or from one LEA to
another LEA), the mandates of any IEP current at the time of transition remain in effect and must be
met by the new LEA to ensure a free and appropriate public education (FAPE).
o In situations where a student transitions from school age to postsecondary status, the protections of
an IEP are no longer afforded to the individual because IDEA protections only apply to school-age
individuals. The LEA may opt, as a courtesy, to transfer the assistive technology to the individual or
may retain the assistive technology for use by other school-age students.
 If assistive technology was purchased under the student’s MA Funding or private, family insurance, the
device is the property of the student and moves with the student.
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IU 1 Assistive Technology Considerations Checklists
Generally listed in order from no-tech to high-tech, these are types of devices or strategies that could be
employed to meet the student’s needs. Teams should try to identify options that span the range of no-tech,
low-tech, and high-tech interventions when possible, since different settings and tasks will determine which
intervention is most appropriate. Teams should also consider no-tech and low-tech interventions for back-up
use in the absence of high-tech ones (e.g., when AT is being repaired).
AT Intervention for Communication
Yes/no strategy for basic communicative needs
Picture symbols
Photos/digital pictures
Use a communication board/book with pictures, text, or objects
Symbol-authoring software to create boards/activities
Eye-gaze frame with pictures or text
Pen and paper to communicate with text or drawings
Portable keyboard or computer to type messages during conversation
Sign-assisted speech to enhance a student’s receptive communication
Single-level, voice-output communication aid (VOCA)
Multi-level, voice-output communication aid (VOCA)
Voice-output communication aid (VOCA) with icon sequencing
Voice-output communication aid (VOCA) with dynamic display
Voice-output communication aid (VOCA) with synthesized speech
Voice-output communication aid (VOCA) with automatic level switching
Radio frequency identification (RFID) communicator with digitized speech
Speech-generating device (SGD)
Speech-generating device (SGD) with eye gaze interface
Tablet device with a touch screen interface
Switch to access and activate device when direct selection is not an option
Keyguard for use of the communication device
Carrying case for the communication device
Stylus or T-stick to activate the communication device
External speakers/speaker case to amplify sound for listeners
External headphones
Additional battery, charger, and/or AC power cord
AT Intervention for Computer/Tablet Access
OS-level accessibility options for keyboarding (e.g., Sticky Keys, repeat rate)
Abbreviation expansion (AutoCorrect or Replace) to reduce keystrokes
AutoText to reduce keystrokes
Word prediction to reduce keystrokes or assist spelling and word use
Keyguard to assist users in making direct selections
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Arm or chair supports to promote proper positioning
Track ball, joystick, or other alternative mouse in place of a standard mouse
Touchscreen monitor as an alternative input device
Keytop overlays to label keys in both cases
Keytop overlays to promote finger positioning/hand use
Onscreen keyboard for typing
Alternate keyboard or keyboard layout
Head mouse or pointer to type on an onscreen or standard keyboard
Switch as a primary input device
Switch interface for multiple switches and functions
Scanning (auditory, step, radial, etc.) as a means of input
Voice recognition software as a primary means of input
AT Intervention for Mathematics
Graph paper for spacing or alignment
Formatted paper (e.g., guideline papers formatted for an algorithm)
Vertically lined paper to aid alignment/place value
Abacus or math line for calculations
Enlarged work materials (for clarity or spacing)
Calculator or coinulator for computation activities
Calculator that is capable of printing results
Calculator with speech output capability
Calculator with enlarged keys or displays
Measurement tools that feature tactile guides
Measurement tools with speech output capability
Math notation software as an alternative to pencil-and-paper
Drawing or graphing software as an alternative to pencil-and-paper
Virtual manipulatives to provide an access alternative to physical ones
AT Intervention for Organization
Print, picture, or tactile schedule
Color-coding- to organize books, folders, and other materials
Markers, removable tape, or acetate line guides to highlight text
Recorded messages to prompt student behaviors or tasks
Paper organizers for assignments and tasks
Electronic organizers/software for assignments and tasks
Hand-held computers (PDAs) or a tablet device with a touch screen interface for assignments, tasks, and
productivity
Use software to generate graphic organizers (concept development or organization)
AT Intervention for Reading
Predictable books to assist in decoding & comprehension
Decodable text
Styles to maximize accessibility of word-processed documents among potential users
Reading guides/windows
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Scoptic (colored filter) overlays
Altered word spacing
Altered line spacing
Altered text size or color
Symbol-writing software to pair text with symbols or pictures
Electronic tool for pronunciations, spellings, or meanings
Single-word/line scanners to read text aloud
Audio books to supplement printed text
Audio books to replace printed text
Text-to-speech software to read typed text aloud
Digital imaging software to digitize documents
Optical character recognition (OCR) software to digitize and manipulate text
Scan-and-read software to access and annotate text
Books adapted for independent page-turning
Electronic books to allow for easy magnification/transportation
DAISY-formatted text and readers (may be subject to eligibility requirements)
NIMAS file sets (subject to eligibility requirements)
AT Intervention for Seating and Positioning
Consult with the medical provider, wheelchair vendor, physical therapist, and/or occupational therapist
when considering interventions for seating and positioning
Adjustable chair
Adjustable desk or workstation
Foot rest or stool
Solid wedge to promote back extension
Lordosis roll to support back and provide extension
Tactile cushion
Chair with armrests or supports
Supportive chair (e.g., Rifton, Kaye, Thera-Adapt, Lecky)
Chair with additional supports (e.g., laterals, headrest, hip abductor, pelvic belt, chest harness)
Tray or table-top support
Chair with tilt/recline capabilities
Modified work tray, table, or work station
Mounting system (e.g., desktop, rigid, swing-away, folding)
AT Intervention for Sensory Needs
-Consult with the medical provider, audiologist, and/or teacher of the Deaf and hard of hearing when
considering interventions for hearing needs
-Consult with the medical provider and/or teacher of the Blind and visually impaired when considering
interventions for vision needs
Open-captioned materials
Closed-captioned materials
Personal amplification devices (personal FM, infrared system)
Real-time captioning or computer-assisted real time (CART) to transcribe lectures or discussions
Computer-aided notetaking systems
OS-level accessibility options for audible/visual messages
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Handheld or stationary magnifiers
Large-print materials
Braille materials for reading (or labels on keyboards)
Raised-line materials
Tactile graphics
Adjusted screen contrast for improved visibility
Screen magnification software or hardware for monitor visibility
Screen reading software for access to onscreen content
Braille translation software with an embosser or refreshable Braille display
Closed-circuit televisions for magnification/contrast
Video magnifier for magnification/contrast and near/distant viewing
AT Intervention for Writing
Adaptive or alternative grips, pencils, and pens
Harder/softer lead weight to result in lighter/darker line
Non-slip surfaces or clipboards to stabilize materials
Adapted paper (e.g., graph paper, raised-line paper, or highlighted-line paper) to assist with spacing and
organization
Adjusted seat and/or desk heights for adequate posture and support
Slantboard for optimal writing angle
List of prewritten words/phrases
Graphic organizer to structure ideas and content
Cloze notes to reduce the amount of material to be written
Access to full notes as a back-up to student-generated notes
Scribe services when there is no independent means for a student to record notes or ideas
Analog or digital recording device to record lectures/commentary
Printed labels to provide legible answer choices
Label machine to generate legible answers independently
Video pen and paper to capture notes and/or recordings
Portable keyboard
Portable keyboard with text-to-speech capability
Access to a desktop, laptop, netbook, or tablet computer
Spelling and grammar checker
Word prediction software
Text-to-speech software to provide audible reinforcement
Digital imaging (scanning) software to annotate scanned documents
Scan-and-read software to annotate and manipulate contents of scanned documents
Grid-based word processor for composition
Cloze-style word processor for notetaking or assessment purposes
Speech recognition software for extensive writing tasks
iPad/Android apps
AT Interventions – Additional
- 17 -
- 18 -
IU1 Request for Assistive Technology Consultation/Evaluation
Please complete the following Intermediate Unit 1 forms:
*Referral for Assistive Technology Services form, revised 6/7/12
*Assistive Technology Parent Input form (sent by AT Secretary )
*Initial Intake Form (Sent by AT Secretary)
*Vision Assistive Technology Parent Input form (only if requesting assistive technology vision services)
*Vision Assistive Technology Initial Intake form (only if requesting assistive technology vision service)
*Audiological Intake form (only if requesting assistive technology audiological services)
Required Documentation:
*Signed PTE or PTRE (if requesting an AT Evaluation)
*Current ER or RR Date
*Current IEP Date:
*Diagnostic Reading Assessment Date (for reading/writing requests only – if a diagnostic reading assessment
has not been completed within the last school year, one should be completed prior to the submission of the
AT Request):
What is the student’s core reading program?
If any, what reading intervention is being implemented?
Minutes of reading instruction per day
Additional Documentation
The team may also want to include (as appropriate and available):
Previous Assistive Technology Action Plan Date:
Portfolio (include samples of student-generated work with dates on each sample)
Other:
Date:
Team Members (if known, please indicate with an asterisk [*] those team members’ names who
will be attending the meeting following the AT consultation)
Role
District Administrator (LEA)
Building Principal
Lead Teacher/Therapist
General Education Teacher
Special Education Teacher
Speech-Language Pathologist
Parent/Guardian
Parent/Guardian
Building Technology Contact
Name
Email
- 19 -
Phone
Occupational Therapist
Physical Therapist
Teacher of VI/Blind
Teacher of Deaf/HH
Psychologist
Student
Other:
Other:
Other:
- 20 -
REFERRAL FOR ASSISTIVE TECHNOLOGY SERVICES
INTERMEDIATE UNIT 1
Fayette-Greene-Washington
Revised July 7, 2012
I. Service(s) Requested:
Augmentative Communication
Organization
Assistive Listening (FM)
Reading
Computer Access
Written Expression
Mathematics
Vision
Pre Referral Screening- Specify:_____________________________________
Consultation – Specify: ___________________________________________
Initial Evaluation –(Permission to Evaluate)
Due Date:________________
Re-evaluation –(Permission to Re-evaluate)
Due Date:________________
II. Referral Source:
II. Student Specific Information:
Student:
Parent/Guardian:
Mailing Address:
Phone (home):
MA Eligible:
D.O.B.
Grade:
(work/cell):
Yes
No
MA#
School District of Residence:
School Attending:
Contact Person/Role:
Contact Person’s Email Address:
Teacher’s Name:
Teacher’s Email:
PAsecureID
School Phone:
Phone:
Current Program:
* LEA Signature (Required)
Date
Supervisor
Date
Support Staff
Date
Approved By:
Referred To:
- 21 -
NOTE: ALL Assistive Technology Referrals should be sent or faxed to: Assistive Technology Department, IU1
Central Office, One Intermediate Unit Drive, Coal Center, PA 15423 Fax Number: (724) 938-8722
Fayette-Greene-Washington
INTERMEDIATE UNIT 1
One Intermediate Unit Drive
Coal Center, PA 15423
Charles F. Mahoney III
Telephone 724-938-3241 Fax 724-938-8722
Executive Director
www.iu1.org
ASSISTIVE TECHNOLOGY
INTAKE FORM
Identifying Information:
Student Name
Date of Birth
Age
Home School District
School Attending
Grade
If Kindergarten:
Arrival Time
AM
PM
Departure Time
School Address
Classroom Teacher
Email Address
Phone
LEA
Email Address
Phone
FAX
Date Form Completed
Person(s) Completing Form
Position/Relationship to Student
Assignment (for office use only)
LATC
- 22 -
Date
Student/Team Availability
Please indicate the days and time periods that the student and team members are available for onsite visits.
Approximately 3 hours will be needed for the consultation and team meeting.
Monday
AM
PM
Tuesday
AM
PM
Wednesday
AM
PM
Thursday
AM
PM
Friday
AM
PM
Special scheduling concerns:
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 access to computers
Increase reading comprehension
Assist with organization of school work
Provide an efficient means of note taking
Enable him/her to take tests and demonstrate
Provide activities for recreation/leisure
Assist with spelling
Improve the quality of written composition
Provide access to the Internet/leisure
Increase the speed of his/her typing
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?
- 23 -
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
If YES, please select from the list below.
Autism
Emotional Disturbance
Orthopedic Impairment
Other Health Impairment
Speech/Language Impairment
Traumatic Brain Injury
NO
Deaf-Blindness
Intellectual Disability (Mental Retardation)
Hearing Impairment, including Deafness
Specific Learning Disability
Visual Impairment, including Blindness
3. Description of Educational Services:
Does the student have a current IEP?
YES
NO
If YES, please attach a copy of the IEP and ER/RR.
Does the student receive any support services? YES
NO
If YES, please check the services receiving:
Speech/Language Support
Vision Support
Hearing Support
Medication
Physical Therapy
Behavior Management
Occupational Therapy
Other:
Is there an IEP team in place?
YES
NO
If YES, check and list appropriate team members:
Check
Role
Name(s) print clearly
Student
Parent(s)
Speech & Language
Pathologist
Occupational Therapist
- 24 -
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
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
- 25 -
Can a person unfamiliar with the student understand the response?
Most of the time
Sometimes
Rarely
Writing: Check all that apply.
Holds pencil, but does not write
Scribbles with a few recognizable letters
Uses a pencil adapted with
Copies from book (near point)
Prints a few words
Prints name
Writes cursive
Writing is limited due to fatigue
Writing is slow and arduous
Hand Dominance
Right Hand
Pretend writes
Uses regular pencil
Copies simple shapes
Copies from board (far point)
Writes on 1" lines
Writes on narrow lines
Uses space correctly
Sizes writing to fit spaces
Writes independently and legibly
Left Hand
Not established
Written work:
Short assignments:
Writes independently
Uses computer
Other
Dictates to another writer
Asks for minimal assistance
Writes independently
Uses computer
Dictates to another writer
Asks for minimal assistance
Reports:
Other
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:
- 26 -
Trackball
Joystick
Head pointer
Other:
Touch screen
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
Specify:
Uses one hand
Uses two hands
Attention Level:
Attends appropriately
Has difficulty staying on task
Very short attention span
Behavior:
Self-stimulatory
Aggressive
Avoidance
Student’s Learning Style:
Auditory
Kinesthetic
Attention Seeking
Escape/Runner
Other:
Visual
Multiple Modalities
If so, please list:
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
Description of Seating:
Seating provides trunk stability
Seating provides 90/90/90 position
Sits in wheelchair
Has difficulty using table or desk
Seating allows feet to be on the floor
Has difficulty with head control
- 27 -
Best position for head control is:
Please specify:
Desk Accessibility:
Uses regular desk
Uses desk with height adjusted
Uses adapted table
Uses wheelchair for desktop
Hearing:
Within Normal Limits
Hearing Loss
Right Ear
Left Ear
Bilaterial
Aided
Type of Loss
Conductive
Sensorineural
Central
Mixed
Date of last audiological evaluation: ____________________________________________________
Vision:
Within Normal Limits
Loss of Vision
Right Eye
Severity of Loss
Low Vision
Left Eye
Corrective Lenses
Legally Blind
Completely Blind
Date of last vision evaluation: ____________________________________________________
Medical Considerations:
History of seizures
Has degenerative medical condition
Has multiple health problems
Has frequent ear infections
Has allergies to
Currently taking medication for
Other – Describe briefly
Fatigues easily
Has frequent pain
Has digestive problems
Has frequent upper respiratory infections
Include Additional Information, Questions and Concerns:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
- 28 -
Fayette-Greene-Washington
INTERMEDIATE UNIT 1
One Intermediate Unit Drive
Coal Center, PA 15423
Telephone 724-938-3241 Fax 724-938-8722
www.iu1.org
Charles F. Mahoney III
Executive Director
Assistive Technology
Parent Input Form
Please return the completed form to IU1 AT Secretary, Melissa Margraff, at the IU1 Central Office.
Address: One Intermediate Unit Drive
Coal Center, PA 15423
Fax Number: 724-938-8722
E-mail: margraffm@iu1.k12.pa.us
Client’s Name: ______________
Birth Date: ________________
Age: __________
Parent/Guardian Name: __________
Address: ______________________
______________________
Preferred Time/Method of Contact:
___________________________________
Home Phone: ________________________
Work Phone: ________________________
Email Phone: ________________________
What outcomes would you like as a result of this referral?
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
How do you think assistive technology may help your child? Check a maximum of 3
Practice academic skills
Provide access to computers
Increase reading comprehension
Provide an efficient means of note taking
Increase the speed of his/her typing
Improve the quality of written composition
Provide activities for recreation/leisure
Assist with spelling
Assist with organization of school work
Enable him/her to take tests and demonstrate
what s/he knows
Provide access to the Internet/leisure
Other
- 29 -
Please list your child’s strengths, learning style, interests, and any other significant
factors that should be considered:
Strengths: ___________________________________________________________________________
Learning style (auditory, visual, kinesthetic, etc.): ___________________________________________
Other:
Student’s present means of communication:
Check all that the student uses and underline primary method the student uses
Changes in breathing patterns
Vowels, vowel combinations
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
Reliable No Response
Combo picture/symbols
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
Signs
Vocalizes
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
Child’s typical attention level:
Attends appropriately
Has difficulty staying on task
Very short attention span
Behavior:
Self-stimulatory
Aggressive
Avoidance
Attention Seeking
Escape/Runner
30
Pictures
Word
Home Computer Use: Check all that apply and list titles of software
No computer is available at home
Internet browsing
Child does not use computer at home
Academic skills practice
Plays computer games
Homework
Word processing
Email
Other:
Computer availability at home:
None
Mac (version_______)
Windows 2000 XP
Windows Vista
Windows 7
Microsoft Office version:
2010
2007
2003
Earlier version
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
Specify:
Uses one hand
Uses two hands
Current mouse/mouse alternative use: Check all that apply
Uses mouse:
Independently
With assistance
Uses adaptive equipment:
Trackball
Head pointer
Touch screen
Joystick
Other:______
Homework:
Reading:
Reads independently
Listens to material read by an adult
Asks for assistance with some words
Uses computer
Math:
Uses calculator
Uses computer
Uses manipulatives
Other:
31
Listens to books on tape
Uses video magnifier
Other:______
Written work:
Short assignments:
Writes independently
Uses computer
Asks for minimal assistance
Dictates to another writer
Other:
Reports:
Writes independently
Uses computer
Asks for minimal assistance
Dictates to another writer
Other:
Math:
Uses a calculator
Uses computer
Uses manipulatives
Other: ______
What difficulties does the student have in learning new material or studying?
Check all that apply
Remembering assignments
Reviewing notes from lectures
Remembering steps of tasks or assignments
Organizing information / notes
Finding place in textbooks
Organizing materials for a report or paper
Taking notes during lectures
Turning in assignments
Other:
Please summarize your child’s abilities and your concerns related to homework:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
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
Desk Accessibility:
Uses regular desk
Uses desk with height adjusted
Sits in wheelchair
Has difficulty using table or desk
Uses adapted table
Uses wheelchair for desktop
Description of Seating:
Seating provides trunk stability
Seating provides 90/90/90 position
Best position for head control is
Specify: ___________________
Seating allows feet to be on the floor
Has difficulty with head control
32
What assistive technology/accommodations have you tried, or are currently being tried with
your child? List when and with what level of success.
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________________________________________
Include Additional Information, Questions and Concerns:
_______________________________________________________________________________
_______________________________________________________________________________
___________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
______________________________________________________________________________
______________________________________
Parent Signature
________________________
Date
33
Fayette-Greene-Washington
INTERMEDIATE UNIT 1
One Intermediate Unit Drive
Coal Center, PA 15423
Charles F. Mahoney III
Telephone 724-938-3241 Fax 724-938-8722
Executive Director
www.iu1.org
VISION ASSISTIVE TECHNOLOGY
INITIAL INTAKE SCREENING
Student:
D.O.B:
Home District:
District/Building Attending:
Grade:
If Kindergarten
Arrival Time:
AM
PM
Departure Time:
School Address:
School Phone:
Classroom Teacher:
Contact Person:
E-mail:
Phone Number:
Fax:
School Nurse:
E-mail:
Phone Number:
Date Form Completed:
Person(s) Completing Form:
34
Please answer the following questions to maximize the evaluation:
Does the student currently have an IEP?
yes
no
IF YES, PLEASE ATTACH A COPY OF THE IEP AND ER/RR
Please check appropriate team members and add their names if there is a team in place:
Student:
Parent(s):
Speech & Language Pathologist:
Occupational Therapist:
Physical Therapist:
Special Education Teacher:
Regular Education Teacher:
Paraprofessional:
Psychologist:
Teacher of the Visually Impaired:
Orientation & Mobility Instructor:
Teacher of the Hearing Impaired:
Counselors:
Principal:
LEA:
Other:
While at school, what does the student need to do that he/she cannot currently do?
Does the student have a disability?
If yes, please describe.
yes
no
Describe the student’s abilities:
Strengths:
Vision:
What type of learner is the student?
visual
auditory
tactile
What method or material accommodations have you employed thus far?
What assistive technology device(s), if any, does the student currently have?
What assistive technology device(s), if any, does the student currently use?
35
What are the pros and cons of those devices?
What type of assistive technology do you feel would be a benefit at school?
computer access
enlargement capabilities
auditory access
writing tools
other:
Other information that you feel would be helpful when conducting the assistive technology
evaluation:
36
Fayette-Greene-Washington
INTERMEDIATE UNIT 1
One Intermediate Unit Drive
Coal Center, PA 15423
Charles F. Mahoney III
Telephone 724-938-3241 Fax 724-938-8722
Executive Director
www.iu1.org
VISION ASSISTIVE TECHNOLOGY PARENT INPUT
Student:
Birthdate:
Date form completed:
What is your son/daughter’s visual diagnosis?
Has he/she ever had a Clinical Low Vision Evaluation?
If yes, approximately how long ago?
yes
no
The definition of Assistive Technology to help you answer the following questions:
Assistive Technology is any item, piece of equipment, or product system that is used to increase,
maintain, or improve functional capabilities. Examples would be: Bold line paper or pens,
CCTV’s, Magnifiers, Computer Software, auditory books, etc.
What assistive technology devices are you aware of that your son/daughter uses at school to
help him/her with schoolwork?
What assistive technology devices does your son/daughter use at home for schoolwork or leisure
activities?
While at school, what does he/she need to do that he/she cannot currently do?
37
Describe your son/daughter’s abilities:
Strengths:
Vision:
What type of assistive technology do you feel would be a benefit at school?
computer access
enlargement capabilities
auditory access
writing tools
other:
Other information that you feel would be helpful when conducting the assistive technology
evaluation:
___________________________________________
Parent Signature
___________________________
Date
38
Fayette-Greene-Washington
INTERMEDIATE UNIT 1
One Intermediate Unit Drive
Coal Center, PA 15423
Telephone 724-938-3241
Charles F. Mahoney III
Executive Director
Fax 724-938-8722
www.iu1.org
Assistive Listening (FM) Technology
Parent Input Form
Please return the completed form to IU1 AT Secretary, Melissa Margraff, at the IU1 Central Office
Address: One Intermediate Unit Drive
Coal Center, PA 15423
Fax number: 724-938-8722
E-mail: margraffm@iu.k12.pa.us
Child’s Name: ____________________________
Birth Date: ________________ Age ________
Parent/Guardian Name: ____________________
________________________________________
Address: ________________________________
________________________________________
Preferred Time/Method of Contact:
_________________________________________
Home Phone: ______________________________
Work Phone: ______________________________
Cell Phone: _______________________________
E-mail: __________________________________
What are your primary concerns with your child in the educational setting?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________
What types of situations have you noticed your child having hearing difficulties?
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_____________________________________________________________________________________
Age child’s hearing loss was identified?
_____________________________________________________________________________________________
Age when amplification (hearing aids) was fit?
_____________________________________________________________________________________________
Name of private audiologist:
_____________________________________________________________________________________________
Contact information: Address/phone number:
__________________________________________________________________________________________________
__________________________________________________________________________________________
39
Make and model of hearing aids: Right ear:
______________________________________________________________________________________________
Make and model of hearing aids: Left ear:
______________________________________________________________________________________________
Degree of hearing loss left ear/ right ear:
_______________________________________________________________________________________________
Most recent audiogram:
_____________________________________________________________________________________________
Is your child a consistent hearing aid user?
_____________________________________________________________________________________________
Can your child indicate when the hearing aid battery dies?
_____________________________________________________________________________________________
Can she/he change the hearing aid battery?
_____________________________________________________________________________________________
Can your child independently take out and put on his/her hearing aids?
______________________________________________________________________________________________
____________________________________________________________________________________________
List any health issues or daily medications:
______________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
Does your child have a history of ear infections? Does child have an ENT (ear, nose, throat) Doctor? Has your
child ever had tympanostomy (pressure equalization) tubes?
______________________________________________________________________________________________
____________________________________________________________________________________________
_____________________________________________________________________________________________
Is there a family history of hearing loss?
_____________________________________________________________________________________________
Is the cause of your child’s hearing loss known?
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________________________________________________
40
What is your child’s current academic performance? grades? strengths? weaknesses?
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________________________________
Any concerns with your child’s communication skills?
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________________________________________________
Is your child receiving any special services in his/her educational setting? (examples: OT, PT, Speech,
Learning support, Hearing support, social work, TSS)
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
__________________________________________________________________________________________
Include Additional Information, Questions, and Concerns:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
_________________________________________________________________________________________
What outcomes would you like as a result of this referral?
______________________________________________________________________________________________
______________________________________________________________________________________________
___________________________________________________________________________________________
___________________________________________
Parent Signature
__________________
Date
41
Student – What are the
student’s strengths and
needs?
Environment – Where are
the needs noted? Who
teaches or supports the
student in these settings?
Tasks – What must the
student do to meet
lesson or IEP goals? What
do peers do in
comparison?
Tools – What no-tech,
low-tech, and high-tech
tools have been used or
considered?
Barriers
What we need to know
What we know
Questions
The SETT Framework – Part I, Collaborative Consideration of Student Need for
Assistive Technology Devices and Services
©Joy Zabala, 20001. PERMISSION GRANTED TO USE IF CREDITS ARE RETAINED. Please provide feedback on
effectiveness and suggestions for modificaitons/revisions by email to joy@zabala.com
Modified by Montgomery County; MD Public Schools Assistive Technology Team; Modified by Allegheny
Intermediate Unit #3; adopted by Intermediate Unit 1 July 2012.
LEA/Liaison Review & Approval
The AT Request for Consultation, the student’s Evaluation Report (ER) or Reevaluation Report (RR) and Individualized Education
Plan (IEP) should be submitted to Justine Phillips, Intermediate Unit 1 Program Supervisor, c/o Melissa Margraff/IU1 Assistive
Technology Secretary, One Intermediate Unit Drive Coal Center, PA 15423 Fax- 724-938-8722
42
The LEA’s name, email and review date must be completed.
Name:
Email:
Phone:
Date:
43
The SETT Framework – Part II, Incorporating AT into School Tasks
List the academic and social activities that occur in each content area. Instructional grouping may have an impact on the technology that can be utilized.
Tasks
Describe the type of task that the student is
expected to perform
Technology Tools to Use
Use descriptions and general terminology followed
by specific product names
Implementation Considerations
Describe staff supports, environments, prep work,
or settings required for use of the tool
From the work of Donna Shaw, Adapted by Kelly Fonner, http://www.kellyfonner.com/, kfonner@earthlink.net, Modified by Allegheny Intermediate Unit #3; adopted by Intermediate Unit 1 July 2012
44
Assistive Technology Trial Period Plan and Rating Scale
AT to be trialed
Environments for
the AT trial
AT Trial Period
(Enter date range)
Indicators of Effectiveness
(Predetermined by team based
on rate, duration, accuracy,
quality, etc.)
Outcomes
(How did performance change? Attach
work samples or pre- and post-trial
data sheets)
Created by Montgomery County, MD Public Schools Assistive Technology Team, Modified by Intermediate Unit #1; adopted by Intermediate Unit 1 July 2012
45
Success
Rating
(1, high
– 5, low)
Assistive Technology Roles and Responsibilities Matrix
Adapted by Kelly Fonner, http://www.kellyfonner.com/, kfonner@earthlink.net, Modified by Intermediate Unit 1; adopted by Intermediate Unit 1 July 2012
46
District Tech Staff
Building Tech Staff
Psychologist
Other Administrator
Building Principal
AT Consultant
Physical Therapist
Occupational Therapist
Speech Language Therapist
Paraeducator
General Educator
Special Educator
Parent
List all actions that must be done for this student. For each
item, agree on a team member who is (A) accepting
responsibility for completing the action step and one who is
available to serve in a (B) back-up role for the action step.
Team members should speak for themselves rather than be
assigned to items. No one person should assume primary
responsibility for all items. Each team member should assume
primary or back-up responsibility for at least one item.
Discuss AT recommendations and alternatives with buildinglevel/district-level technology staff prior to trials or
implementation
Facilitate short-term loans from vendors or PaTTAN on behalf
of the team (upon request)
Facilitate short-term loans from the PIAT AT Lending Library
(requires the signature of the LEA for financial liability
purposes)
Provide demonstrations/training on the AT hardware or
software that is implemented as part of a trial (upon request)
Collect data during the trial period (in accordance with team
decisions outlined on the previous page of this action plan)
Student
Responsibilities (Refer to Page 2 of this plan for contact info)
(A) Primary responsibility (B) Back-up support