AT Assessment Checklist

Assistive Technology General Assessment/Checklist

STUDENT:
AGE:
DATE(s):
SCHOOL/PROGRAM:
AUXILLORY SCHOOL/PROGRAM:
GRADE IN SCHOOL/GRADE COMPLETED:
ASSISTIVE TECHNOLOGY ASSESSMENT TEAM MEMBERS:
REASON FOR AT ASSESSMENT:

Ask in each area if the need can be met No Tech (free), Low Tech (minimal cost) or High Tech (commercial level hardware and software) and add that to the “NOTES” for each section.

Ask in each section what the anticipated goal or outcome is. Will the person use items to fulfill school and/or work needs, do they really need the tem(s), and what might be a timeframe? Put the answers from the AT Team in the “NOTES” section at the end of each section.

Download Checklist Link

Physical Factors

Totally Blind __

Deaf/Blind __

Low Vision __

Partially Sighted __

Visual Learning Needs __

Totally Deaf __

Hard of Hearing __

Cochlear Implant __

Hearing Aids __

Glasses __

Learning Disabilities (visual/auditory/kinesthetic/tactile) __

Cerebral Palsy __

Helmet __

Amputee __

Prosthetic limb(s) __

Prosthetic eye(s) __

Speech Impediment __

Progressive Disorder (MS and others) __

Syndrome __

Tactile Defensive __

Walker __

Wheel Chair __

Standing Table __

One handed __

Missing fingers __

Hand/Finger coordination issues __

Arthritis __

Other __

NOTES:

Cognitive Factors

Learning Disabilities __

Syndrome __

Cognitively Challenged __

Slow Learner __

Emotional Disturbance __

Attention Deficit Disorder __

Processing Disorder __

Language Delay __

Cannot filer out external sounds or stimuli __

Other __

NOTES:

Behavior(s) General (measurable) behavior goals for IEP link

Average __

Passive __

Anxious __

Obsessive/Compulsive __

Aggressive Physically __

Aggressive Verbally __

Passive/Aggressive __

Over Reacts to Specific Stimuli __

Is responsible for belongings of self and others (school) __

Other __

NOTES:

Health

Good __

Fatigues easily __

Progressive decline (MS, RP, Glaucoma, Diabetes, Cancer) __

Asthma __

Seizures __

Other __

NOTES:

Primary Language

English __

Spanish __

French __

German __

Russian __

American Sign Language (ASL) __

Other __

NOTES:

Secondary Language

English __

Spanish __

French __

German __

Russian __

American Sign Language (ASL) __

Other __

NOTES:

Mobility

Independent in room __

Independent in building __

Independent outside __

Independent in vehicle __

Uses White Cane __

Uses wheelchair __

Uses walker __

Cannot follow simple route(s) __

Disorients in room easily __

Requires sighted guide __

Other __

NOTES:

Furniture

Standard __

Foot rest __

Padded table __

Standing table __

Cubicle __

Adjustable chair __

Wheel chair designed table __

Other __

NOTES:

Lighting

Standard __

Low light __

Bright light __

Overhead light issues __

Window light issues __

Lamp __

Soft light __

Color of light __

Wears sunglasses inside (extreme photophobia) __

Other __

NOTES:

Reading

Standard sized print __

Large print __

Braille Uncontracted __

Braille Contracted __

Audio __

Other __

NOTES:

Writing

Print __

Typed __

Braille __

Audio __

Other __

NOTES:

Keyboarding Typing Programs Link

No skills __

Independent without looking, using correct fingering __

Looks at keys __

Two fingered typist __

Standard keyboard __

Large keys keyboard __

One handed keyboard __ FrogPad2 Link Half QWERTY Link Matias Half Keyboard Link One Handed Keyboards Link

Laptop keyboard __

Tactile markings on keyboard __

Other __

NOTES:

Mouse

Standard __

Roller ball mouse __

Mouse that connects around finger __

Track Pad __

Stylus __

Other __

NOTES:

Computer

None __

Windows XP, 7, 8 __ Windows Key C

MAC __

Linux (i.e. Ubuntu) __

Chrome Book __

Laptop __

Tower __

Other __

NOTES:

Monitor

Size __

On desk __

On monitor swivel arm __

Dimmed __

Brightened __

High Contrast __

Reverse Contrast __

Other __

NOTES:

Refreshable Braille Focus Blue Braille Display Link Braille Edge Link BrailleNote Apex Link

14 cell __

20 cell __

32 cell __

40 cell __

80 cell __

Other __

NOTES:

Productivity Programs

Microsoft Office __

Microsoft Office online __

OpenOffice __ OpenOffice Link

Google Docs __ Google Docs Link (you need to establish a Google account, probably via Gmail)

MAC word processor, spreadsheet, presentation, and any other __

Other __

NOTES:

Adaptive Software/Programs

EVAS Guide __ (very simple, menu driven program suite for non-power users; includes email, word processing, internet, calculator, spell check and more) EVAS Guide Link

ZoomText with Speech __ ZoomText Link

ZoomText without Speech __

ImageReader for ZoomText __ ImageReader Link

Magic __ Magic Link

JAWS __ JAWS Link

WinEyes __ WinEyes Link

NVDA __ NVDA Link

VoiceOver (iPhone/MAC) __ VoiceOver Link

Kurzweil 3000 __ Kurzweil 3000 Link

Kurzweil 1000 __ Kurzweil 1000 Link

Kurzweil 1000 with HoverCam __

Openbook __ OpenBook Link