| Assistive Technology and Educational Adaptation Survey
Prior to your child's next IEP meeting, to better prepare to educate your child, take the time to respond to this survey so as to help staff, working with your child, to prepare for Assistive Technology (AT) modifications or educational Adaptations (EA) you would like to see incorporated in your child’s educational and/or therapeutic program through your child's IEP.
There are many types of Assistive Technology (AT) modifications and Educational Adaptations (EA), which your child may be able to benefit from, or is already currently using. Just a few of the AT areas include:
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Communications (symbol-picture boards, electronic communication devices, etc.)
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Mobility and Seating (power and manual wheelchairs and seating systems) |
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Fine Motor Control (adaptive writing instruments, hand positioning splints, adaptive utensils, etc.) |
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Computing (trackballs, word prediction software, laptops, etc.) |
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Receptive Hearing (FM units, hearing aids, etc.) |
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Reading (books on tapes, computer software, etc.) |
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Auditory Training (FastForward, Earobics, etc.) |
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Cognition (training software products) |
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Hearing augmentation (fm unit, hearing aids, etc.) |
These are a few of the Educational Adaptations (EA), which may benefit your child in the academic arena:
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Mathematical calculations (calculator) |
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Handwriting adaptations (computer, laptops with portable printer) |
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Reading (books on tapes, CD, DVD, MP3) |
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Test Taking (tests on tape)
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Fill out this information first:
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Name of Parent or Guardian responding |
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Relationship to the target child for whom you are responding |
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Address: City: State: Zip: |
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Telephone: Work Phone: Fax: |
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Email: |
Please indicate your target child’s:
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Name: |
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Age: |
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Gender: |
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Grade Level: |
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Educational and/or medical diagnosis: |
My target child currently attends a school which is:
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Public and its name is: |
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Private and its name is: |
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Home Schooled: |
1. My target child currently has assistive technology equipment and related therapy expenses paid for by (put an x in front of the insurance or third party payors for the medical and technology supports your child has):
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Family Health Insurance Plan
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Medicaid
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Medicaid Waiver
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State Developmental Services Purchase of Materials
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Assistive Technology Grant from Public School under the IDEA
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Grant from a Civic Organization or National Charity (Please Specify):
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Other source (Please Specify):
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2. The amount of support and time available to implement Assistive Technology or Educational Adaptation services in the classroom may be different depending on the classroom environment. Please put an x in front of what best describes your child’s classroom environment.
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Self-contained classroom
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Resource room support (2-3 hours a day) and in regular classes rest of day
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Fully included in a regular classroom all day with an attendant
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Fully included in a regular classroom all day with no attendant
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Other (Please describe):
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3. Put a check in front of which therapies or services your child currently receives and indicate where and degree of frequency when asked:
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Physical Therapy (frequency and location [school, private]):
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Occupational Therapy (frequency and location [school, private]):
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Speech Therapy (frequency and location [school, private]):
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Sensory Integration Therapy (frequency):
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Auditory Integrattion Therapy (frequency):
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Visually Impaired Services (frequency):
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Auditory Impaired Services (frequency):
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Specific Learning Disability Services (frequency):
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Recreation Therapy (frequency):
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4. Please rate the perceived comfort level of the professionals who are currently working with your child concerning utilizing Assistive Technology (AT) to assist your child to be more functional in everyday activities.
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Extremely supportive and currently implementing AT services for your child at this time
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Very supportive and offer many AT suggestions and alternatives for use now
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Supportive offered information about AT as a possibility some day but not now
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Rarely supportive has slightly mentioned AT but never as a possibility for my child
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Non supportive refuses to consider an AT alternative for my child or has never mentioned AT to me
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5. Please rate the perceived comfort level of the professionals who are currently working with your child concerning utilizing Educational Adaptations (EA) to assist your child to be more functional in school and everyday activities.
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Extremely supportive and currently implementing EA services for your child at this time
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Very supportive and offer many EA suggestions and alternatives for use now
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Supportive offered information about EA as a possibility some day but not now
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Rarely supportive has slightly mentioned EA but never as a possibility for my child
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Non supportive refuses to consider an EA alternative for my child or has never mentioned AT to me
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6. Place an X next to each specific functional difficulties your child currently experiences which impairs full functional performance at school, in the community, or at home.
In communications your child needs:
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Total assistance: has extremely limited communications skills |
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Maximal assistance: frequent interpretations of child’s communications are needed |
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Moderate assistance: uses simple language to tell about own needs and activities |
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Minimal assistance: expresses self clearly almost all of the time |
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Prompting/setup: caregiver or other adult may need to give some prompting or cueing when the child is communicating with less familiar people |
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No assistance and is Independent: can be readily understood by others all of the time |
Other needs:
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problem hearing – severe hearing deficit or loss
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problem seeing – severe visual deficit or loss
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problem with long distance mobility (walking long distances)
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problems with fine motor control (please specify):
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other physical movement problems (please specify):
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problem with mathematical computations
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problem with handwriting
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problem with reading comprehension
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problem with reading books or stories
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problem spelling words
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other cognitive problems (please specify):
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problem paying attention to directions
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problem with remembering directions
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inability to follow or understand geographical directions
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problem behaviors interfere with conduct in a classroom or social setting
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problem with relating to peer group in a social setting
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other (please specify):
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7. Is your child aware of Assistive Technology? yes no
8. Is your child aware of Educational Adaptations? yes no
9. What does your child think about Assistive Technology (AT):
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Extremely motivated and currently implementing AT services at this time
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Very motivated and openly participates in the search for AT alternatives for use now
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Motivated has shown openness to information about AT as a possibility
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Poorly motivated has never shown interest in possibility of AT for self
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Not motivated refuses to consider or participate in any AT alternative at all
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10. What does your child think about Educational Adaptations (EA)
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Extremely motivated and currently implementing EA services at this time
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Very motivated and openly participates in the search for EA alternatives for use now
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Motivated has shown openness to information about EA as a possibility
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Poorly motivated has never shown interest in possibility of EA for self
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Not motivated refuses to consider or participate in any EA alternative at all
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11. Please list what Assistive Technology and/or Educational Adaptation products you are currently considering or have considered using in the past (e.g. Adapted keyboard, electronic communication device, writing aids, etc)
Assistive Technology
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2
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3
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4
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5
The following questions are for those parents who have already used Assistive Technology and/or Educational Adaptations in the past with their child, or who have had previous experience attempting to obtain AT/EA in the past.
12. list all of the Assistive Technology and Educational Adaptations your child is currently using or has used in the past? Please rate 1-5 on how successful the AT/EA device has been for your child? Use the following rating scale:
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1=Very productive and helps my child to “fit in” in all arenas of life
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2=Productive helps my child to be more capable of being able to function adaptively in many aspects of life
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3=Adequate is useful to help my child be reach minimum academic competency requirements
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4=Minimally useful had some use to help my child progress but was not transferable to all aspects of my child’s life
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5=Useless it was a waste of time pursuing this device for my child
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Assistive Technology Device … Rating
Educational Adaptive Device… Rating
13. List each Assistive Technology and Educational Adaptation device your child is currently using and fill in the following information:
How often is AT/EA devise used? D=daily, F=frequently, I-infrequently
Where is it used : H=home, S=school, C=community
1. Assistive Technology Device
2. Assistive Technology Device
3. Assistive Technology Device
1. Educational Adaptation Device
2. Educational Adaptation Device
3. Educational Adaptation Device
14. Up until this time how did you obtain funding for your child’s Assistive Technology and Educational Adaptations?
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private insurance
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Medicaid
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Medicaid Waiver
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state agency
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federal agency
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school
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local agency
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community charity or civic club
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cash – on your own
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15. Choose as many of the following statements which you would use to describe the entire Assistive Technology and Educational Adaptation process (evaluation, funding, implementation, follow-up):
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very productive experience
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worth the time and aggravation
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waste of time and energy
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made a world of difference in my child’s life and that made it worth the effort
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did little for my child thus it was a waste of energy and effort
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lots of red tape, very confusing and took too long to get what my child needed
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invaluable learning experience on what to do and not do for my child
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hopeful and enlightening because it opened a new world for my child
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relieving since it offered a modification which would enable my child to be better to handle the responsibilities and requirements facing him in school, at home, and in the community
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16. What would you like to change about your child’s Assistive Technology and Educational Adaptation experience? (please describe):
17. How knowledgeable have the professionals (OT, PT, SLP, Teacher) been in implementing Assistive Technology and Educational Adaptations in the past?
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Experts: I have complete faith that they know what’s best for my child and will carry it through in school
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Very good: They have carefully thought out the process and identified multiple solutions. An AT plan should be in their IEP at this level. |
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Adequate: They came up with helpful ideas that had a positive impact, but carry over and implementation was inconsistent. |
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Inadequate: They were not able to identify AT/EA solutions that were suitable or did not use the suggested AT appropriately. |
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Poor: They did not know which types of AT/EA might be available for my child and/or refused to implement suggested AT/EA.
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