Assistive Technology Assessment Report

Report Title: Assistive Technology Assessment Report

Individual: [Individual full name], [DOB], [MRN or Student ID]

Assessment Date(s): [Assessment date(s)]

Report Date: [Report date]

Location(s): [clinic / home / school / workplace / community / remote]

Evaluator(s): [Evaluator name(s), credentials, discipline, organization, contact information]

Referral Source: [Referral source name, role, organization]

Referral Purpose: [medical funding / school access / workplace accommodation / community participation / other]

Distribution List: [Recipients outside originating record: names, roles, organizations] (Only include if sharing is intended and consent obtained)

Executive Summary

(Provide a concise snapshot for decision-makers. Use observable language and state expected outcomes with measurable targets.)

• Referral Question: [Primary question and reason for AT assessment]
• Primary Functional Barriers: [Prioritized list of barriers impacting participation/performance]
• AT Trials Completed: [High-level overview of tools trialed and outcomes]
• Top-Line Recommendations: [Primary recommended AT system and key accessories/services]
• Training/Implementation & Follow-Up Summary: [Initial training plan and follow-up checkpoints]
• Justification Statement: [One-paragraph summary of medical necessity and/or educational access rationale]

Baseline Metrics and Expected Outcomes: [Baseline metric 1] → [Expected outcome]; [Baseline metric 2] → [Expected outcome]; [Baseline metric 3] → [Expected outcome]

Consent and Information Sharing

Consent Status: [Consent obtained for evaluation and device trials: verbal / written]

Release of Information: [Status and named recipients] (If consent not yet obtained: "Consent to share with [recipient]: not yet obtained; recommendations provided for clinical/team planning only.")

Record Type: [Health record / education record / both]

Communication Accommodations: [Interpreter, accessible formats, AAC supports used, if any]

Background and Relevant History

(Summarize only information directly relevant to AT selection. Label each source: patient report, caregiver report, teacher report, record review, direct observation, or trial data.)

• Diagnoses/Conditions: [Condition(s), onset, course, prognosis if known] [source]
• Functional History: [Relevant functional abilities/limitations; endurance, accuracy, speed, independence] [source]
• Prior AT Exposure and Outcomes: [Tools previously used, duration, effectiveness, abandonment reasons if any] [source]
• Educational/Vocational Context: [Grade/role, core tasks, IEP/504/accommodations] [source]
• Sensory/Motor/Cognitive/Communication Considerations: [Factors affecting device access] [source]
• Unknown/Not Assessed: [Items not available or deferred]

Assessment Team and Data Sources

• Participants: [Names and roles: individual, caregivers, educators, therapists, AT specialist(s), vendor support]
• Records Reviewed: [Prior evaluations, IEP/504/AT plans, device history, funding decisions, therapy notes]

Functional Needs and Prioritized Tasks

(Identify relevant functional domains: communication, reading access, written expression, computer/device access, mobility/positioning for access, ADLs/IADLs, vision/hearing access.)

Task	Setting	Baseline	Barriers	Success Metric	Priority
[Task name/description]	[home / school / clinic / workplace / community]	[Observable baseline with source]	[access / cognitive-linguistic / environmental / tool]	[Measurable criterion]	[high / medium / low]
[Additional tasks as needed]

Environment and Access Constraints

• Primary Environments: [Home, school, clinic, workplace, community; typical schedules and contexts]
• Technology Ecosystem: [Allowed platforms; network constraints; authentication requirements; LMS/EHR/app compatibility]
• Physical Constraints: [Positioning, mount points, glare, noise, portability, durability]
• Human Supports: [Available supports for setup, troubleshooting, charging, transport]
• Policy/Permission Notes: [Device capability vs. environment permission distinctions]

Baseline Performance and Barriers

(Quantify baseline performance using speed, accuracy, endurance, cueing level, error patterns, fatigue/pain, and assistance required.)

• Task-Level Baselines: [Task: objective baseline data] [source]
• Barrier Categorization: [Access barriers (motor/sensory), cognitive-linguistic barriers, environmental barriers, tool barriers]
• Safety Considerations: [Positioning hazards, choking/entanglement risk, skin breakdown, falls, hearing safety]
• If Baseline Not Formally Obtained: [Reason and structured observational findings used]

Assessment Methods

• Approach: [Task-based functional assessment / feature-matching / SETT framework / other]
• Settings Observed: [Location(s), dates, contexts]
• Measures Used: [Standardized tools, informal probes, dynamic assessment methods]
• Trial Design: [Duration, tasks attempted, success/failure criteria, cueing levels]
• Limitations: [Single session, tele-assessment, device availability constraints] (Include plan to validate via extended trial if indicated.)

AT Trials

(Document each tool trial to be auditable and reproducible. Repeat for each tool.)

[Tool #1: Manufacturer, Model, Software/App Version]

• Accessories/Configuration: [Switches, mounts, keyguards, cases, profiles, vocabulary sets, accessibility settings]
• Access Method: [direct touch / eye gaze / switch scanning / keyboard-mouse alternative / voice input / stylus / head mouse / other]
• Setup Requirements: [Positioning, calibration, lighting/noise prerequisites, seating/mounting]
• Training Provided: [What was taught, by whom, duration, prompting level]
• Performance Data: [Baseline vs. with-tool performance; speed, accuracy, endurance, cueing level] [trial data]
• User/Caregiver Feedback: [Preference, comfort, stigma concerns, perceived workload] [patient/caregiver report]
• Observed Issues: [Reliability, breakdown points, cognitive load, policy barriers, fatigue/pain]
• Disposition: [successful / partially successful / not successful] (Include reasoning linked to data.)

[Tool #2: Manufacturer, Model, Software/App Version]

(Repeat structure for each additional tool. If a desired tool could not be trialed, document why, proxy evidence used, and validation needed before procurement.)

Trial Comparison Summary

Tool	Pros	Cons	Data Highlights	Environmental Fit	Training Burden	Recommendation Status
[Tool name]	[Key advantages]	[Key disadvantages]	[Compelling data points]	[Platform/policy/physical fit]	[low / moderate / high]	[recommend / alternative / not recommended]
[Additional tools as needed]

Recommendations

(State recommendations using neutral, objective language. Reference trial data and environment fit.)

• Primary Recommended AT System: [Device type and model class]; Accessories: [mounts, switches, keyguards, stylus, case]; Configuration: [profiles, vocabulary sets, accessibility settings]; Compatible Alternatives: [Acceptable equivalents if exact model unavailable]
• Secondary/Backup Options: [Low-tech backups, redundancy plan, offline procedures]
• Required AT Services: [Setup/customization, programming, integration, caregiver/staff training] (Tag each as required or optional.)

Training and Implementation Plan

Skill	Trainer	Learner	Setting	Frequency	Mastery Criteria	Target Date
[Operational / strategic / functional / partner skill]	[AT specialist / therapist / educator / caregiver]	[Individual / caregiver / staff]	[home / school / clinic / workplace]	[Frequency and duration]	[Observable mastery criterion]	[Target date]
[Additional skills as needed]

Follow-Up and Outcome Monitoring

• Follow-Up Timeline: [Schedule based on risk and complexity]
• Data Plan: [What will be measured, by whom, how often, reporting method]
• Reassessment Triggers: [Developmental change, device abandonment signals, environment/policy changes, medical decline, repeated repairs]

Justification

Medical Necessity

(Include when AT recommendation requires medical funding authorization.)

• Diagnosis/Condition and Severity: [Condition(s) and functional impact in home/community]
• Why AT Is Medically/Functionally Necessary: [Link to functional limitations and participation goals]
• Why Less Costly or Standard Options Are Insufficient: [Reference trial data and environment constraints]
• Expected Duration of Need: [Timeframe]
• User Ability and Support Plan: [Cognitive/physical ability to use with support]
• Training and Follow-Up: [Explicit plan summary]

(If not written by ordering clinician: "This report provides evaluative support; the treating practitioner must complete the order and any required face-to-face documentation per payer policy.")

Educational Access

(Include when AT recommendation is for school-based access.)

• Access to Curriculum and Materials: [How AT supports access and participation]
• Independence and Demonstration of Knowledge: [Link to educational tasks and trial data]
• Setting Scope: [school only / across settings] (Include rationale for home use if recommended.)

Safety and Maintenance

• Safety Risks Identified: [Positioning hazards, choking/entanglement, skin breakdown, falls, hearing safety]
• Maintenance Plan: [Charging, cleaning, updates, backup procedures, repair pathway, replacement cycle]
• Environmental Risks: [Theft/loss mitigation, data privacy, access controls]

Assessment Limitations

• [What could not be assessed and why]
• [Constraints that may change recommendations]
• [Tele-assessment limitations if applicable]

Signatures and Attestations

Evaluator Signature: ____________________________ Date: _____________

Printed Name/Credentials/License #: [Name, credentials, license number]

Co-Signature (if applicable): ____________________________ Date: _____________

Treating Practitioner Acknowledgment (if supporting ordering): ____________________________ Date: _____________

Appendices

(Note which appendices are attached.)

• [Appendix A: Detailed trial logs]
• [Appendix B: Device specifications and configuration notes]
• [Appendix C: Photos/diagrams of positioning/mounting]
• [Appendix D: Vendor quotes with part numbers]
• [Appendix E: Training materials]
• [Appendix F: Records reviewed]