AHSD 25 Assistive Technology Background Information Form

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Email *

Student Name *

Date of Birth *

Grade/Room#:

Date of Referral: *

YYYY

School *

Referred by (name & title): *

Another School Contact (name & title) *

Parent/Guardian:

Have the areas of concern been discussed with the complete educational team?

Yes, please provide date (in Other: blank)

Other:

Discussed with parents?

Yes, please provide date (in Other: blank)

Other:

Please provide 2 Special Ed Team meeting dates for Robyn to attend two weeks from now: (Robyn will confirm date with team leader)

Disability: (Check all that apply)

Autism

Cognitive Impairment

Learning Disability

Emotional Disability

Deaf/Blind

Developmental Delay

ADHD

Hearing Impairment

Speech/Language

Multiple Disability

Vision Impairment

Orthopedic Impairment

OHI

504

Traumatic Brain Injury

Classroom Settings: (Check all that apply)

General Education

Resource

Self-Contained

List Special Education Services the child is receiving:

This student needs support to:

Support Communication (Student is nonverbal or unintelligible)

Access School Curriculum

Describe what it is that this student is expected to do in order to achieve his/her IEP goals that s/he is not able to do/perform/achieve with the current interventions that are being used by the school (instructional strategies, modifications, adaptations, etc)

What data or tracking method have you used to demonstrate that the current modifications/adaptations are not enough to meet this student's needs? Please describe and attach any data.

Medical Considerations: (Check all that apply)

History of seizures

Has a degenerative medical condition

Has multiple health problems

Fatigues easily

Has frequent pain

Wears glasses

Takes medication

Medical diagnosis: (Fill in Other: blank)

Other:

Vision Impairment (receives VI services) Yes or No If yes, please explain:

Hearing Impairment (receives HI services) Yes or No If yes, please explain:

Motor (check all that apply)

Child Walks

Child uses wheelchair

Child can carry an object 2-5 lbs

Can use a computer mouse

Can hold a pencil

Can print/copy words

Can type slowly

Can use a switch (explain type and body part for access in Other: blank)

Other:

Are there any behavior considerations (both positive and negative) that may impact the student's performance:

Any Additional Comments:

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