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Idaho Assistive Technology Project

School-based Student Assessment Application

Type of Assessment:*
Initial Assessment
Follow-up Assessment

Student Information

Application Date:

Student's Name:*

Birth Date:*

Age:*

Student's Grade:*

Parent Information

Parent's Name:*

Email Address:*

Street Address:*

City:*

State:*

Zip Code:*

Applicant's Information

Person Completing the Application

Name:*

Email Address:*

School Contact Information

Contact's Name:*

Email Address:*

Phone Number:*

School Address

School Name:*

School District Number:*

Street Address:*

City:*

State:*

IEP Team Members

IEP Team Members:

****List the Team Members in the space provided. Please provide the following info Team Member, Title, Email Address, Phone Number******

Additional Student Information

Classroom Setting:*
Home
Regular Education Classroom
Resource Room
Self-contained
Other

Disability:*

Check all that apply

Autism
Cognitive Impairment
Developmental Delay
Emotional/Behavioral Disability
Hearing Impairment
Learning Disability
Orthopedic Impairment
Severe Multiple Impairments
Speech/Language
Traumatic Brain Injury
Vision Impairment

Current Related Services Received:*
Behavioral Therapy
Instructional Assistant
Occupational Therapy
Physical Therapy
Speech Therapy
Transportation
Other

Medical Considerations

Currently taking Medication for:*

Has an allergy to:*

Other Medical Considerations:*
Fatigues easily
Has degenerative medical condition
Has digestive problems
Has frequent ear infections
Has frequent pain
Has frequent respiratory infections
Has multiple health problems
History of seizures
Other

Assistive Technology Currently Used

Mobility, Seating & Positioning:
Manual Wheelchair
Seating & Positioning

Communication:
Augmentative Communication System

Hearing/Vision:
Amplification Systems
Vision Aids

Learning (reading, writing, organization):
Low tech Writing Aids
Voice Recognition
Word Prediction

Computer Access:
Computer
Alternative keyboard and mouse
Voice Recognition
Word Prediction

Daily Living:
Daily Living
Environmental Control Unit

What task(s) does the student need to do that is currently difficult or impossible,
and for which assistive technology may be an option?:

In other words, please list your student's goals that may be helped through
the use of assistive technology.

Please describe the assistive technology that has been previously tried
the length of time you tried each, and the outcome.:

(how did it work, or why it did not work)

Please complete all summaries that apply to your student

Computer/Device Access:

Summary of Student’s Abilities and Concerns Related to Computer/Device Access

Motor Aspects of Writing:

Summary of Student’s Abilities and Concerns Related to Writing

Composing Written Material:

Summary of Student’s Abilities and Concerns Related to Composing
Written Material

Communication:

Summary of Student’s Abilities and Concerns Related to Communication

Reading:

Summary of Student’s Abilities and Concerns Related to Reading

Learning and Studying:

Summary of Student’s Abilities and Concerns Related to Learning and Studying

Math:

Summary of Student’s Abilities and Concerns Related to Math

Recreation and Leisure:

Summary of Student’s Abilities and Concerns Related to Recreation and Leisure

Seating and Positioning:

Summary of Student’s Abilities and Concerns Related to Seating and Positioning

Mobility:

Summary of Student’s Abilities and Concerns Related to Mobility

Vision:

Summary of Student’s Abilities and Concerns Related to Vision

Hearing:

Summary of Student’s Abilities and Concerns Related to Hearing

Are there any behaviors (both positive and negative) that significantly
impact the student’s performance?:

Are there significant factors about the student’s strengths, learning style,
coping strategies or interests that the team should consider?:

Idaho Assistive Technology Project - University of Idaho - Center on Disabilities and Human Development

121 West Sweet Ave. - Moscow, ID 83843 - Phone Toll-free: 1-800-432-8324 - Fax: 208-885-6145

Email: idahoat@uidaho.edu

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