Sample AT Forms

Today in most school districts the provision of assistive technology is managed through a paper based system of forms and other documents.  Our intent here is to share with you samples of forms that are being used by districts who are willing to share their work with you.  Please use these as examples that can inform the creation or review of the forms being used in your district.

AT Consideration

Outcomes of AT Consideration Flowchart

Assistive Technology Consideration Checklist

Possible Outcome Sample Statements with Student Examples

List of Assistive Technology to Consider for Different Areas (this list is not all inclusive)

Dr. Wojcik's Sample Assistive Technology Consideration Sample Form

Assistive Technology Consideration Data Collection Sample Form


          AT Service and Delivery Flow Chart                                     

AT Request Form                                                             

Intake Form                                                                                                                     

AT Consult Form                                                              

SETT Checklist

Updated Tools/Feature Chart

Updated SETT I

Updated SETT II

Updated SETT III


Written Productivity Profile Directions

Written Productivity Profile

Device Eval I  

Device Eval II


AT Implementation Plan

AT Training Form

Eisenhower Implementation Form

Data Collection

Communication Training

Initiated Communication

Latency of Response

Mouse Evaluation

Performance Data

Product Production

Switch Data Sheet

System Comparison

Vocabulary Use

Voice Output Device Activations

Writing Speed and Accuracy