Student & Team Info
Student ID
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School ID or other Unique ID
Student Name
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First Name
Last Name
District
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District
School
School Placement
Grade
Classification
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Diagnoses & Profile Summary
Assessment Start Date
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Month
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Day
Year
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Assessment Team Info
First Name
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Title
Team Lead
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Select all areas of concern
Communication
Yes
No
Device Access
Yes
No
Executive Function
Yes
No
Hearing
Yes
No
Math
Yes
No
Reading
Yes
No
Seating & Positioning
Yes
No
Sensory (i.e., hyper/ hyposensitive)
Yes
No
Vision
Yes
No
Writing (i.e., handwriting; composition)
Yes
No
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Complete each area of concern
Skip any areas or items that do not apply
Communication (skip any items that do not apply)
Identify all communication methods used by the student:
Facial expressions
Body position
Breathing pattern
Eye movement/gaze
Head movements (e.g., shakes, nods)
Gestures
Pointing
Guiding to items
Signs or sign language approximations (if checked, complete corresponding field below)
Vocalizations
Word approximations
Single words
Two-word utterances
Three-word utterances
Communication picture board with pictures
Communication picture board with symbols (if checked, complete corresponding field below)
Communication visual scenes board
Object/tangible communication board
Communication binder with multiple pages
PECS system
AAC device or app (if checked, complete corresponding field below)
Other
Add other methods used to communicate
Add the signs or sign approximations used
Symbol system used for communication board
(e.g., PCS, SymbolStix, LAMP, etc.)
Communication binder - list symbols used and number of pages
(e.g., pictures; 3 pages)
Speech Generating Device or AAC app used
(e.g., LAMP WFL, TouchChat, TD I-16 with eye gaze)
Speech Characteristics
Unintelligible
Babbles
Word approximations
Semi-intelligible
Intelligible
If speech is semi-intelligible, what is the estimated intelligibility rate
(e.g., 50% intelligibility)
Expressive Language Age Approximation
Familiar communication partner understands student's communication/attempts
Yes - always
Yes - most or some of the time
No
Unfamiliar communication partner understands student's communication/attempts
Yes - always
Yes - most or some of the time
No
Expressive communication attributes:
Wants & Needs
Social interactions
Social etiquette
Denials & Rejections
Requires verbal prompts
Requires physical prompts
Turns toward communication partner when responding
Names objects
Names pictures
Uses appropriate facial expressions
Comments
Shares stories or information
Asks questions
Initiates interactions
Responds to interactions
Repairs breakdowns
Uses correct syntax
List examples of expressive communication intent/purpose
Receptive Language Age Approximation
Responds to communication partner (e.g., directions, instructions, greetings, etc.)
Yes - consistently
Yes - inconsistently
No
Receptive communication attributes:
Follows one-step directions
Follows two-step directions
Follows multi-step directions
Understands gestures or signs
Turns toward communication partner when addressed
Answers questions
Identifies objects
Identifies pictures
Understands parts of or the whole story when read aloud
Answers basic comprehension questions about text read aloud
Answers complex comprehension questions about text read aloud
Pre-Reading & Reading Skills
Recognizes objects
Recognizes pictures
Recognizes symbols (e.g., SymbolStix, PCS)
Sight word recognition
Environmental print recognition
Summarize pre-reading/reading skills related to communication
Physical considerations for device selection
Ambulatory without assistance
Ambulatory with assistance (e.g., adult, walker, etc.)
Uses a wheelchair
Drops or throws items
Carries objects or classroom materials independently
Requires touchscreen access
Requires eye-gaze system
Requires auditory preview
Requires a switch with scanning
Requires a keyguard
Requires a sturdy case with handle
Requires a sturdy case with carrying strap
Requires a sturdy case with stand to angle on device on a desk/table
Summarize switch/scanning ability, if a switch is required
(e.g., one or more reliable switch site identified; type of switch needed - use the switch/scanning assessment category if not already determined)
List any sensory sensitivities to consider for AAC tool selection (e.g., volume, tactile (Velcro), etc.)
Summarize communication expectations for the student
(e.g., expectations in classroom, physical education, playground, extra-curriculars, home, and community)
Current use of AAC device (if applicable)
Doesn't attend to device
Attends when device use of modeled
Selects symbols without intent
Select symbols with intent
Selects symbols representing highly preferred items/activities
Combines two symbols
Combines three or more symbols
Current grid size of low-tech picture board/binder or high-tech device/app
(e.g., 4, 8, 32, 60, 96)
If a larger grid is being used, are you using the hide feature to not show all the buttons (e.g., 60 grid but hiding all but 10 buttons, unhiding when student is ready to learn a new word)
Yes
No
Grid size should be based only on the student's fine motor and visual abilities and not perceived cognitive abilities. Anytime a grid size is changed, the location of the buttons changes, therefore, student has to relearn the system. If not using the largest grid size student can physically and visually access, explain why:
For example, team believes student can only four pictures at a time, so instead of selecting largest accessible grid size and hiding buttons, they selected a smaller grid.
Current communication strategies used
Consistently Used by All Team Members
Consistently Used by Some Team Members
Only Used in Therapy
Not Used
Modeling of current AAC system (i.e., picture board, AAC app)
Total Communication Approach (i.e., all communication is accepted/acknowledged)
Communication Temptations (i.e., placing preferred items out of reach)
Recasting (i.e., correct or add information such as when student is frustrated, language expressing this feeling is modeled)
Expanding (i.e., student points to a snack; communication partner models language requesting the item)
Manding (i.e., ABA communication technique)
Wait time before prompting
Natural consequences (i.e., student selects unpreferred item, which is then presented to student)
Core word learning (i.e., motivating activities or books are used to teach core words)
List other strategies used (currently or previously)
Summarize student's current communication abilities and concerns
Communication Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Objects
Photographs
Tangible symbols
Communication board
Communication book/binder
PECS
PODD
Single message voice recorded device (e.g., BIGmack)
Multiple message voice recorded device (e.g., GoTalk 9+)
Single message voice recorded device with levels (e.g., Little Step-by-Step)
Multiple message voice recorded device (e.g., GoTalk 20+)
Speech generating/voice recorded device with icon sequencing (e.g., ProxTalker or LAMP WFL app)
Dynamic display AAC device/app (e.g., TD Snap, NovaChat)
Text-based device with speech output
List any other low, mid or high tech AAC systems used (currently or previously)
Explain why any assistive technology was indicated above as not beneficial.
Device Access (skip any items that do not apply)
Computer/Device Used
Chromebook - no touchscreen
Chromebook - touchscreen
iPad
Android tablet
Windows Surface
Mac laptop - no touchscreen
Mac laptop - touchscreen
Mac desktop
Windows laptop - no touchscreen
Windows laptop - touchscreen
Windows desktop
Typing Skills
Doesn't currently use a computer
Doesn't currently use a tablet
Uses touchscreen
Doesn't currently type
Requires wrist or hand support
One-finger hunt & peck typing
One-handed hunt & peck typing
Two-handed hunt & peck typing
Voice typing/dictation
Uses an alternative keyboard
Uses an alternative mouse
Uses another alternative input method (e.g., headmouse, eye gaze, switch)
Student presents with physical or motor limitations that affect access
Not applicable
Abnormal muscle tone
Abnormal relexes
Fatigues easily
Fine motor deficits
Range of motion deficits
Hearing impairment
Sensory sensitivities (i.e., tactile, visual, auditory)
Visual perception delays
Visual impairment
Other
List all other physical/motor limitations affecting access
Student presents with seating and positioning issues that affect access
Not applicable
Uses a regular chair with adaptations (e.g., wedge cushion, back support)
Uses an adapted chair
Uses a footrest
Uses a wheelchair
Other
List any other adaptations or supports used to improve positioning
Summarize the student's abilities and concerns related to device access
Device Access Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not beneficial
Standard keyboard with no adaptations
Standard keyboard with adaptations (e.g., high contrast letter stickers)
Standard mouse with no adaptations
Standard mouse with adaptations (e.g., slower movement, highlighted pointer)
Standard trackpad with no adaptations
Standard trackpad with adaptations (e.g., custom gestures)
Built-in OS accessibility features (e.g., sticky keys, zoom)
Text-to-speech
Screen reader
Voice typing/dictation
Magnification/Zoom features
High contrast
Word prediction
List any other assistive technology hardware/software used (currently or previously)
Explain why any assistive technology for device access noted above was not beneficial for the student
For example, student used a text-to-speech program but they hated the computerized voice and refused to use it.
Executive Function (skip any items that do not apply)
Student has difficulty with
Working memory
Long-term memory
Impulsiveness or speaking out of turn
Initiating tasks
Emotional regulation when completing difficult tasks
Distracting self or others
Completing tasks
Planning task completion
Breaking tasks into smaller, more manageable tasks independently
Staying focused
Arriving on time and ready to work
Adapting to changes in schedule
Self-evaluating performance
Adjusting behavior based on reaction of others
Setting and achieving goals
Perseverance when presented with harder tasks
Organization - select all areas of concern
Messy desk
Messy locker
Messy backpack
Loses paper materials
Misses assignment due dates
Disorganized notes
Following multi-step directions
Time management
Other
List any other areas of concern pertaining to organization
Explain all non-technology based strategies used to help with organization
Executive Function Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Color-coding
Folder/binder system
Visual schedule
Prompting
Checklists
Paper planner
Digital planner
Traditional timers
Visual timers
Fidgets or other self-regulation tools
Digital material storage (i.e., Google Drive versus paper folders)
Visual supports
Flexible seating
List any other assistive technology tools used (currently or previously)
Explain why any previously used assistive technology was indicated as not beneficial.
Hearing (skip any items that do not apply)
Unaided Hearing
Check all areas of concern
Student has difficulty attending to the following types of sounds
Low pitches
High pitches
Voices
Student has difficulty with the following
Background noise
Sound discrimination
Hearing all or some speech sounds
Turning toward a sound
Understanding digitized (computer-based) speech
List any other areas of concern
Student's eye contact and attention with communication partner is:
Very good/excellent
Good
Limited
Inconsistent
Poor
Very poor
Describe hearing based on most recent audiological exam
Describe receptive and expressive language abilities and proficiency, noting any discrepancies between the two.
Select all communication strategies used by the student
ASL
Body language
Gestures
Speech
Visual supports (e.g., symbols, pictures)
Written
List any other communication strategies used
Summarize student's abilities and concerns related to hearing
Hearing Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Hearing aids
Personal FM system
Room amplification system
Closed captions
Real time captions
ASL
Text supports
Visual supports
Tactile supports
Alerting devices (e.g., visual or vibrating)
List any other assistive technology tools used (currently or previously)
Explain why any previously used assistive technology was indicated as not beneficial.
Math (skip any items that do not apply)
Difficulty with or understanding the following
Math vocabulary
Math facts
Money concepts
Time concepts
Units of measurement
Percentages
Decimals
Place values
Word problems
Meaning of representational formats (i.e., numbers, shapes)
Meaning of visual representations (i.e., charts, graphs)
Meaning from word problems and applying steps
Organizing work on a page
Applying correct operations
Applying formulas
Organizing multi-step problems
Mixed numbers
Other
List all other areas of difficulty reading or understanding of math concepts
Difficulties with writing or presenting math work
Writing legibly
Drawing math figures, charts, graphs, etc.
Aligning numbers when solving problems
Graphing numbers or data sets
Solving simple addition problems
Solving complex addition problems
Solving simple subtraction problems
Solving complex subtraction problems
Solving simple multiplication problems
Solving complex multiplication problems
Solving simple division problems
Solving complex division problems
Writing simple math equations
Writing complex math equations
Editing math problems
Other
List all other areas of concern for written math work
Describe all non-technology based strategies used to help with math
Summarize the student's abilities and concerns related to math
Math Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Adapted paper
Manipulatives including adapted
Measuring tools including adapted
Math lines
Calculator
Adapted/alternative calculator
Math graphic organizer
Visual math supports
Digital worksheets
Virtual manipulatives
Voice typing
Math software
List all other assistive technology tools used (currently or previously)
Explain why any assistive technology was indicated as not beneficial.
Reading (skip any items that do not apply)
Approximate reading grade level
Accommodations/modifications used to improve performance/curriculum access
Additional time
Colored overlays
Visual tracking guide
High contrast
Enlarged print
Increased word spacing
Increased in spacing
Specific font
Picture/visual supports
Quiet location with fewer distractions
Smaller amounts of text per page
Text rewritten to current reading level
Pre-teaching concepts
Text read aloud (person or computer)
List all other accommodations or modification used
Describe all non-technology based strategies used to assist with reading.
Physical access issues (e.g., student has a physical disability that affects turning pages in a paper book)
Not applicable
Papers/Worksheets
Books
Digital text
Issues affecting the understanding of written language
English language learner
Limited background knowledge
Learning disability
Developmental disability
Speech/language disorder
Visual impairment
Sensory difficulties
Visual clutter
Lighting
Noise
Other
Difficult with decoding text materials
Worksheets
Books
Tests
Websites or digital text
Modified text
Difficulty with comprehending text materials
Worksheets
Books
Tests
Websites or digital text
Modified text
List any other areas of difficulty or concern related to reading or selections made above
Summarize student's abilities and concerns related to reading
Reading Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Visual tracking tools (e.g., highlighters, reading guides)
Colored overlays
Talking books or audiobooks
MP3 audio files
Bookshare
Learning Ally
Handheld reading pen
Electronic/digital text
Text-to-speech
List any other reading assistive technology used (currently or previously)
Explain why any assistive technology was indicated above as not beneficial.
Seating/Positioning (skip any items that do not apply)
Current seating
Regular chair with no supports needed
Regular char with pelvic supports
Regular chair with foot rest/supports
Adapted chair
Cushion for positioning
Cushion for sensory input
Wheelchair (complete corresponding section below)
List all specific seating/positioning systems currently used
Does current seating meet the student's needs for:
Proper trunk positioning
Proper pelvic/hip positioning
Head control
Allowing feet to sit flat on floor
Comfort
Performing desk work
Wheelchair (WC) needs (skip if not applicable)
WC system provides proper support/positioning
WC system does not provide proper support/positioning
WC system provides all day comfort
WC system provides comfortable positioning for most of the day
WC system provides comfortable positioning for a short time during the day
Student has prescribed positioning requirements in/out of WC
Student requires time out of chair due to discomformt
Multiple positioning options are provided throughout the day
Few positioning options are provided throughout the day
Desk Needs
Regular desk
Height adjustable desk
Regular desk with slant board
Standing desk
Adapted table
Wheelchair tray as desk
Kinesthetic input (e.g., foot swing)
List any other adaptations or desk supports needed
Summarize current seating/positioning concerns
Seating & Positioning Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Standard chair at correct height/seat depth
Standard chair with back support (e.g., lumbar cushion)
Standard chair with foot support (e.g., footrest)
Standard chair with lateral support (e.g., armrests)
Standard chair with cushion for positioning (e.g., wedge)
Standard chair with cushion for sensory input (e.g., wobble)
Alternative/Flexible seating (e.g., ball chair; wobble stool)
Adapted chair (e.g., Rifton)
Sidelyer
Stander
Custom fitted wheelchair
Standard desk at correct height
Standard desk at correct height
Standard desk with slant board
Angled or angle adjustable desk
Height adjustable desk
Standing desk
Wheelchair accessible desk
List any other assistive technology used for seating and positioning
Explain why any assistive technology was indicated above as not beneficial.
Sensory (skip any items that do not apply)
Identify areas where the student experiences hypersensitivity (over-sensitive) or hyposensitivity (under-sensitive).
Describe specific response as needed.
Sensitivity Response
Displays Sensitivity
Hypersensitive
Hyposensitive
Describe the response
Touch from another person
Yes
No
Textures
Yes
No
Clothing
Yes
No
Touches everything
Yes
No
Uneven surfaces
Yes
No
Craves physical activity
Yes
No
Moves constantly
Yes
No
Spinning
Yes
No
Swinging
Yes
No
Rocking
Yes
No
Deep pressure
Yes
No
Bright lights
Yes
No
Visual clutter (too many items/colors)
Yes
No
Visual stimuli (throws/spins items)
Yes
No
Stimming
Yes
No
Loud sounds
Yes
No
Smells
Yes
No
Specific foods/textures
Yes
No
Crowded spaces
Yes
No
Large spaces (e.g., gym)
Yes
No
Small spaces
Yes
No
Vision (skip any items that do not apply)
Date of last vision exam/report
-
Month
-
Day
Year
Date Picker Icon
Describe vision loss based on last eye exam
Describe current visual abilities
(e.g., uses left eye only, tilts head when reading, etc.)
Reading Level - Standard printed text
Reading Level - Braille
Preferred learning or output methods (select all that apply)
Auditory
Tactile
Visual
Multisensory
Font & Size
No modifications needed to read standard printed text (e.g., books, worksheets, etc.)
Needs enlarged text
Needs specific font styles
Preferred font size
Minimum font size (e.g., 16)
Preferred font style(s)
(e.g., Times New Roman, Arial, Verdana)
Color & Contrast
Standard (i.e., black font on white background)
High contrast (e.g., white font on black background; dark mode)
Preferred font color
(e.g., black)
Preferred background color
(e.g., yellow)
Describe lighting needs and preferences
(e.g., overhead lights off; blinds closed)
Handwriting
Not applicable
Copies far point with no issues
Copies near point with no issues
Uses standard lined paper
Uses correct letter spacing
Uses appropriate letter size
Uses bold lined paper
Uses raised-line paper
Uses highlighted paper
Uses bold or colored pens/pencils
List any other accommodations/modifications used for supporting handwriting
Proficiency level that best describes student
Uses supports/devices independently to complete assigned tasks
Able to troubleshoot and problem solve use of supports/devices
Requires intermittent verbal cues
Requires frequent verbal prompts
Requires intermittent physical prompts
Requires frequent physical prompts
Orientation & Mobility
Not applicable
Understands movement concepts (e.g., go, halt, follow, direction, etc.)
Requires human guide
Uses cane with support
Uses cane independently
Uses trailing technique (i.e., back of hand along wall)
Uses visual aids during navigation (e.g., monocular; specialized glasses)
Uses auditory aids during navigation (e.g., talking compass; talking GPS)
Uses tactile aids (vibration) during navigation (e.g., Ray Electronic Aid; WeWalk)
List any other tools or supports used for orientation & mobility
Summarize student's current abilities and concerns related to vision
Vision Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Modified Lighting
Slant board
Reading/tracking guide
Bump dots
Colored overlays
Adapted paper
Alternative pens (e.g., colored; bold; thick; thin)
Manipulatives
Tactile graphics/images
Color filter
Large print text
Handheld magnifier
Desktop magnifier
Video magnifier (e.g., CCTV, portable)
Device magnification (e.g., built-in or 3rd party software)
Screen reader (e.g., built-in or 3rd party software)
Screen reader with magnification
Screen reader with braille device
Audio text (e.g., MP3, audiobooks)
Text-to-speech software
Typing with audio feedback
Typing with braille support
Voice typing/dictation
Slate and stylus
Braillewriter
Refreshable braille device
Large print tools (e.g., rulers, measuring cups)
Tactile measuring tools (e.g., rulers, measuring cups)
Alternative calculator (e.g., large key, talking)
List any other assistive technology used to assist with vision
Explain why any assistive technology was indicated above as not beneficial.
Writing (skip any items that do not apply)
Handwriting (check all areas of concern)
Legibility
Spacing of letters/words
Size of letters/words
Shape of letters
Pencil grasp
Slow/laborious
Copying near point (e.g., from book)
Copying far point (e.g., from board)
Describe pencil grasp style
(e.g., static tripod, dynamic tripod, quadrupod)
List any other concerns relating to handwriting
Describe all non-technology writing strategies used to support handwriting tasks
Computer/Device types used (check all that apply)
Chromebook - touchscreen
Chromebook - no touchscreen
iPad
Android tablet
Mac laptop - touchscreen
Mac laptop - no touchscreen
Mac desktop
Windows Surface
Windows laptop - touchscreen
Windows laptop - no touchscreen
Windows desktop
Does not currently use a device
Keyboarding and Device Access
Does not currently type
Uses a touchscreen
One-handed hunt & peck typing
Two-handed hunt & peck typing
10-finger functional typing
Finger isolation difficulties, hitting unwanted keys
Voice typing
Requires wrist or arm support
Uses alternative or adapted keyboard
Uses other alternative access method (e.g., switch access, eye gaze, mouth or head stick)
List specific alternative keyboards or other access devices/methods used
Describe current device access use including how often, when, and specific tasks
Composition (select all areas of concern)
Getting started with writing tasks
Getting thoughts onto paper
Verbally expressing thoughts
Planning content
Organizing thoughts
Sequencing information
Adding detail
Integrating information from multiple sources
Summarizing
Lack of detail
Limited vocabulary
Poor spelling
List any other areas of concern related to written composition
Strategies currently used to assist with writing
Preset choices
Story or sentence starters
Guided questions
Templates
Word cards/walls/lists
Visual supports
Prewritten words/phrases
Outlines
Graphic organizers/concept mapping
Scribe
Handheld electronic dictionary
Word processing with spelling/grammar checker
Word prediction
Voice typing/dictation
List any other strategies used to support writing
Summarize student's abilities and concerns related to motor and/or written composition
Writing Assistive Technology Currently or Previously Used
Currently Using
Previously Used
Beneficial
Not Beneficial
Adapted pencils
Pencil grips
Adapted paper
Writing templates
Standard keyboard with no adaptations
Standard keyboard with enlarged/high contrast stickers
Adapted/alternative keyboard
Device accessibility features (e.g., zoom, screen reader, sticky keys)
Text-to-speech
Word prediction
Voice typing/dictation
Scanned/digital worksheets
Multimedia or specialized writing software (e.g., PixWriter, Clicker Writer)
List any other assistive technology currently or previously used
Explain why any assistive technology was indicated above as not beneficial
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Student Tasks
List specific tasks the student is required to complete for each area of concern (i.e., communication, reading, writing) with related setting (i.e., classroom/subject, home), barriers preventing student from meeting expectations, and any current supports.
Specific Task
Area(s) of Concern
Setting
Current Barriers
Current Supports
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Setting Characteristics
Types of settings where assistive technology will be used (select all that apply)
One classroom
Multiple classrooms
Playground
Gym
Home
Community
Work
Recreational/Extra-curricular activities
List any other settings to consider for use of assistive technology
Lighting Characteristics
Setting
Too bright/glares
Insufficient lighting
Adjustable overhead lighting
Adjustable window lighting
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Sound Level
Setting
Loud
Quiet
Balanced/Calm
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