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Application
 

School-Based Assessment

Assistive Technology Technical Assistance (ATTA) Application 

Idaho Assistive Technology Project

Center on Disabilities and Human Development

129 West Third St., Moscow, ID  83843

800-432-8324

 

Complete the following application, giving as much detailed information about the student as possible.  Submitted applications will go to the IATP office to be reviewed and assigned to an Assistive Technology Practitioner (ATP).  You will receive confirmation of receipt of your application in three business days..  If you need help completing the application, have any questions, or have not received a confirmation of the receipt of your application, please call Nora at 1-800-432-8324 or email Nora Jehn.

Initial Assessment                  Follow-up Assessment
Student's Name:  
Date of Birth:  
 mm/dd/yyyy
School:  
Age:  
Student's Grade:  
Person Completing Application:  
School Contact Person:  
School Contact Email:  
School Contact Phone:  
  xxx-xxx-xxxx
School Address:  

Team Members: (Should include student, parents, principal, general and special education teachers, and other support staff important to the student)

Team Member Title E-mail Phone

Parent's Address:  

 

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 – type
Severe Multiple Impairments
Speech/Language
Traumatic Brain Injury
Vision Impairment

 

Current Related Services Received (Check all that apply)

Occupational Therapy
Physical Therapy
Speech Therapy
Behavioral Therapy
Transportation
Instructional Assistant
Other – 

 

Medical Considerations (Check all that apply)

Currently taking medication for 
Fatigues easily
Has an allergy to
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 – Describe briefly

 

Assistive Technology Currently Used (Check all that apply)

None
Amplification Systems
Augmentative Communication System
Computer Access – Type
Computer – Type
Daily Living - Type
Environmental Control Unit
Low Tech Vision Aids
Low Tech Writing Aids
Manual Communication Board
Manual Wheelchair
Positioning and seating – Type
Power Wheelchair
Voice Recognition
Word Prediction
Other

 

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)

Describe the student’s interests and likes

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 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?

Thank you for completing the Assistive Technology Technical Assistance Application. If you need any help or have any questions, please do not hesitate to contact Nora. She can be reached at the IATP, 800-432-8324 or (208) 885-3630.

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129 West Third Street Moscow, ID 83843    Phone: 208-885-3557    Fax: 208-885-3628
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