Scottsdale Unified School District
Assistive Technology Consult Request Form - AT2
Student’s Full Name:
Student ID:
School:
Submitted by:
DOB:
Grade:
Title:
Date Submitted:
Program:
Room #:
Please provide contact information for all involved personnel:
Case Mgr.
OT
PT
SLP
VI
HI
Psych
Other
Please indicate the following area(s) of access this consult request pertains to:
Reading
Communication
Physical Access
Writing
Vision
Sensory, tactile, etc.
Math
Hearing
Other
Please explain how the student is not achieving the desired level of success for the area(s) of concern.
Please indicate documented independent levels for:
Reading
Writing
Please indicate what was previously tried or is currently being done to address and
improve the areas of concern specified above?
Communication
Consulted with local campus Speech Language Pathologist
Single Photographs or Symbols used for Picture Exchange
Single message voice output switch
Sentence strip with carrier phrase used for Picture Exchange
Situation specific language display used on:
voice output device - name of device:
manual or eye gaze board
Class iPad with communication app - name of app:
Student voice output device
Other, please describe:
Writing
Consulted with local campus Occupational Therapist
Specialized writing instrument:
grip splint
pencil holder
Adapted writing surface: no slip writing surface slant board
adjustable table height
Special paper (raised lines, bold lines, etc.)
Decrease length of assignment/number of responses
Change format of assignment to multiple choice/fill in the blank
Paper based word lists, dictionary, thesaurus, or peer review
Writing templates/thinking maps
Portable electronic dictionary/thesaurus/spell checker
Word processor/computer
Input method variation: strategies keyboard mouse joystick touchscreen onscreen keyboard
infrared head tracker
eye gaze system
Electronic worksheets
Writing support software/apps:
Electronic thinking maps
Word prediction
Word or phrase banks
Sentence building activities
Voice dictation software/apps
Oral dictation
Other, please describe:
Reading
Standard Textbooks & Supplemental Readers
Simplified books which use repetitive language and/or scenes, sequences, episodes
Changes in text size, spacing, color, background color
Book adapted for page turning (e.g., page fluffers, 3-ring binder)
Use of pictures/symbols with text
Talking electronic device/software to "pronounce" challenging words
Digital Documents/Webpages/Books
Digital Documents/Webpages/Books with Audio Support
Audio Books
Other, please describe:
Math
Manipulatives (Digi-Blocks, etc.)
Abacus, ruler, number line, touch math
Enlarged math worksheets, graph paper
Math Function Tables
Money calculator and Coin-U-Lator
Watches, clocks, or measuring devices with tactile or voice output
Calculator (standard size, enlarged, on-screen, or with voice output)
Alternative keyboards
Math & money computation software (MathPad, Equation Editor, etc.)
Voice recognition software
Oral dictation
Other, please describe:
Learning/Studying
Print or picture schedule
Low tech aids to find materials (index tabs, colored folders)
Highlight text (markers, highlight tape, ruler)
Visual or Auditory reminders for assignments, steps of task, etc.
Digital Planner/Calendar (scheduling device with alarm reminder)
Audio supported books
Record lectures/note taking alternative: Smartpen
mini-cassette or digital recorder
Writing, math, or matching software for concept development/manipulation of objects
Writing software for organizing and generating ideas
Digital snapshot of notes
Scribe assistant or provided notes
Other, please describe:
Fill out schedule for only relevant subject areas in the school year that an A.T. consult is being considered for:
Period
(if applicable)
Subject
Teacher
Rm #
Tasks to consider AT for (area of need):
i.e.: note taking, spelling, written comp., reading, organization, verbal communication
0
1
2
3
4
5
6
7
What days and times are requesting personnel available to meet?
What days and times is the student available?