AT TRIGGER: Screening Document for Potential Assistive Technology Needs

Completion of the following questionnaire will assist in identifying the student's potential need for a consultation regarding assistive technology accommodations and/or evaluation.

For each question with a "yes" response in Section 1, go to the corresponding Potential Need Area in Section 2 below

Student's Name_________________________________

Date of Referral ______________________ Age________ Grade Level_____________

Teacher______________________

Section 1

Physical Characteristics:

Does the student have physical characteristics which significantly set him/her apart from same age peers (i.e., posture/ habits)? Mobility/ Gross Motor:	yes no
Does the student need special assistance to get to and from places? Fine Motor Skills:	yes no
Does the student have difficulty performing basic age appropriate tasks which require the use of hands? Hearing, Speech, Vision:	yes no
Does the student have difficulty in hearing, speaking or seeing? Academic:	yes no
Does the student experience academic difficulties? Recreation and Leisure:	yes no
Does the student have difficulty participating in play-ground activities, sports, or other pastimes? Jobs and Vocations:	yes no
Does the student avoid or have difficulty securing part-time job opportunities? General Health:	yes no
Does the student need assistance with academic tasks due to problems related to alertness, vitality, stamina, strength, endurance, or independent work skills? Self Help:	yes no
Does the student need help from anyone in regard to self help skills, such as eating, dressing, personal hygiene and grooming, or using the restroom?	yes no

Section 2

PLEASE COMPLETE THE FOLLOWING SIMILARLY

FOLLOW-UP SECTION(S) FOR EACH YES RESPONSE FROM SECTION 1

Physical Characteristics	Yes	No	N/A
1. Can the student sit upright while completing tasks at his desk (i.e., not slouched, resting head on desk or hand, etc.)?
2. Can the student participate in and complete classwork regardless of habits (i.e., thumbsucking, chewing on pencils, etc.)
3. Can the student maintain an appropriate posture while seated and actively engaged in a motor task (i.e., key-boarding, cutting)?
4. Can the student participate in playing and running activities without atypical body postures?
5. Can the student sit on floor without assuming asymmetrical postures?
6. Can the student walk independently within the school setting at a rate consistent with that of peers?

Comments: _________________________________________________________

____________________________________________________________________

Mobility/Gross Motor	Yes	No	N/A
1. Does the student have the motor skills necessary to get to/ from school and/ or get around within the school?
2. Can the student participate in physical activities (structured or independent) and navigate within the classroom without tripping or stumbling?
3. Does the student climb and descend stairs independently?
4. Can the student participate in physical activities (structured or independent) and navigate within the class-room without tripping or stumbling?
5. Is the student aware of directionality (i.e., right or left, following the flow of traffic)?
6. Is the student able to maintain balance while performing an activity (i.e., putting on boots, getting up from floor)?
7. Can the student carry objects while walking independently?

Comments: _________________________________________________________

____________________________________________________________________

Fine Motor Skills	Yes	No	N/A
1. Can the student cut and/ or handle scissors independently?
2. Can the student use writing utensils (i.e., markers, paint brush, pencil, crayons) independently?
3. Can the student complete written tasks independently?
4. Can the student copy materials from a book?
5. Can the student copy materials from a board?
6. Can the student tie shoes, button, snap, and/ or use zippers independently?
7. Can the student open doors, turn door knobs or handles, water faucets, pages in a book, and use manipulatives?
8. Can the student keyboard?
9. Can the student draw, form letters, stay on the line, and/or trace?

Comments: _________________________________________________________

____________________________________________________________________

Hearing, Speech, Vision	Yes	No	N/A
1. Does the student speak to communicate?
2. Are others in the school environment able to understand the student's speech?
3. Does the student respond appropriately to speech and noises in the environment?
4. Is the student able to see printed materials presented in the classroom?
5. Is the student able to see toys/ objects in the classroom environment?
6. Is the student able to transfer information from a book, chart, and/ or chalkboard to paper?

Comments: _________________________________________________________

____________________________________________________________________

Academic	Yes	No	N/A
1. Does the student understand the basic cause/effect?
2. Does the student exhibit choice making skills?
3. Does the student have the attention span needed to handle school/daily living tasks?
4. Does the student have the sequencing skills necessary to accomplish school/ daily living tasks?
5. Does the student have the memory and problem solving skills necessary to accomplish school/ daily living tasks?
6. Can the student visually track along a line of print?
7. Can the student read texts independently?
8. Can the student write legibly at a reasonable rate in a reasonable time?
9. Can the student write legibly?
10. Can the student accomplish written tasks?
11. Can the student spell enough of the words needed to communicate in written form?
12. Can the student perform math tasks needed for school or for daily living?
13. Can the student take notes at the level needed in school and/or daily living?

Comments: _________________________________________________________

____________________________________________________________________

Recreation and Leisure	Yes	No	N/ A
1. Is the student able to use the playground equipment?
2. Is the student able to participate in group recreational activities, such as sports and group games?
3. Is the student able to take part in activities requiring fine motor skills, such as board games, art, etc.?
4. Is the student able to participate in extracurricular activities, such as clubs?

Comments: _________________________________________________________

____________________________________________________________________

Return to Appendix C

Go to Appendix D

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