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Assistive Technology Evaluation Questionnaire

Assistive Technology Services, Advancing Opportunities (This section to by completed by: Parent/Guardian)-Please use black ink Student Name: Parent / Guardian Name: E-mail: Sibling Names: Age District: Date:

Directions: Please respond to relevant questions, and skip any questions that you do not have an answer to. Return Questionnaire to: Child Study Team Case Manager What would you like to see your child do that he or she cannot do now?

Definition of Assistive Technology: "Any item, piece of equipment, or product system, whether acquired commercially off the shelf, modified, or customized, that is used to increase, maintain, or improve functional capabilities of individuals with disabilities." What assistive technology, supports, or strategies have you already tried:

What are your child's interests? Sports Book Pets Music Magazines Television

AT Eval Questionnaire Parent

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rev. 11/09



What type of computer equipment is available at home? Microsoft Macintosh 98 OS9 Me XP OS 10 Not sure Other Not Sure

Computer is ____ years old. Who is responsible for technical support for the family computer?

Where is the computer located in the home?

What does your child use the computer for? Homework: Games: Internet / Email: Instant Messaging: 1-2 times a week 1-2 times a week 1-2 times a week 1-2 times a week 3-4 times a week 3-4 times a week 3-4 times a week 3-4 times a week Daily Daily Daily Daily

Please include any other important fact that you would like to share about your child:

AT Eval Questionnaire Parent

Page 2of 2

rev. 11/09


Microsoft Word - AT Eval Questionnaire Parent.doc

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