Wati Assessment Package

WATI Assessment Package
Referral/Question Identification Guide

Students Name
Date of Birth
School
Grade
School Contact Person
Phone
Age
Persons Completing Guide

Date
Phone
Parent(s) Name
Address
Familys Primary Language
Students Primary Language

Disability (Check all that apply.)
Speech/Language
Cognitive Disability
Traumatic Brain Injury
Emotional/Behavioral Disability
Orthopedic Impairment Type
Significant Developmental Delay

Other Health Impairment
Autism
Specific Learning Disability

Hearing Impairment
Vision Impairment
Current Age Group

Birth to Three
Middle School
Early Childhood
Secondary
Elementary
Classroom Setting
Regular Education Classroom
Home
Resource Room
Other
Self-contained
Physical Therapy
Speech Language
Current Service Providers

Occupational Therapy
Other(s)
Medical Considerations (Check all that apply.)
History of seizures
Has degenerative medical condition
Has multiple health problems
Has frequent ear infections
Has allergies to
Currently taking medication for
Other Describe briefly
Fatigues easily
Has frequent pain
Has frequent upper respiratory infections
Has digestive problems
Other Issues of Concern

WATI Assessment Package (2004)
20

Assistive Technology Currently Used (Check all that apply.)
None
Manual Communication Board
Low Tech Vision Aids
Environmental Control Unit/EADL
Power Wheelchair
Voice Recognition
Adaptive Input - Describe
Adaptive Output - Describe
Other
Low Tech Writing Aids

Augmentative Communication System
Amplification System
Manual Wheelchair
Computer Type (platform)_____________
Word Prediction
Assistive Technology Tried

Please describe any other assistive technology previously tried, length of trial, and outcome (how did it
work or why didnt it work.)
Assistive Technology
Number and Dates of Trial(s)
Outcome
Outcome
Outcome
REFERRAL QUESTION
What task(s) does the student need to do that is currently difficult or impossible, and for which
assistive technology may be an option?
Based on the referral question, select the sections of the Student Information Guide to be
completed. (Check all that apply.)
Section 1 Fine Motor Related to Computer
or Device Access
Section 2 Motor Aspects of Writing
Section 8 Recreation and Leisure
Section 3
Section 4
Section 5
Section 6
Section 7
Composing Written Material

Communication
Reading
Learning and Studying
Math
Section 9 Seating and Positioning

Section 10
Section 11
Section 12
Section 13
Mobility
Vision
Hearing
General
21
WATI Student Information Guide

SECTION 1
Fine Motor Related to Computer (or Device) Access

1. Current Fine Motor Abilities
Observe the student using paper and pencil, typewriter, computer, switch, etc. Look at the movements as
well as the activities and situations. Does the student have voluntary, isolated, controlled movements
using the following? (Check all that apply.)
Left hand
Left arm
Left leg
Left foot
Finger(s)
Right hand
Right arm
Right leg
Right foot
Eyebrows
Eye(s)
Head
Mouth
Tongue
Other ________________
________________________
Describe briefly the activities/situations observed
2. Range of Motion
Student has specific limitations to range. Yes No
Describe the specific range in which the student has the most motor control.
3. Abnormal Reflexes and Muscle Tone

Student has abnormal reflexes or abnormal muscle tone. Yes No
Describe briefly any abnormal reflex patterns or patterns of low or high muscle tone that may interfere
with the students voluntary motor control.
4. Accuracy
Student has difficulty with accuracy. Yes No
Describe how accurate, reliable and consistent the student is in performing a particular fine motor task.
22
5. Fatigue
Student fatigues easily. Yes No
Describe how easily the student becomes fatigued.
6. Assisted Direct Selection

What type of assistance for direct selection has been tried? (Check all that apply.)
Keyguard
Pointers, hand grips, splints etc.
Head pointer/head stick

Light beam/laser
Other:_________________________________________________________________________________
Describe which seemed to work the best and why.
7. Size of Grid Student Is Able to Access

What is the smallest square the student can accurately access? 1" 2" 3" 4"
What is the optimal size grid? Size of square__________
Number of squares across__________
Number of squares down__________
8. Scanning
If student cannot direct select, does the student use scanning?
No
Yes, if yes
Step
Automatic
Inverse
Other_________________
Preferred control site (body site)

Other possible control sites
9. Type of Switch
The following switches have been tried. (Check all that apply. Circle the one or two that seemed to
work the best.)
Touch (jellybean)
Joystick
Arm slot
Light touch
Lever
Eye brow
Wobble
Head switch
Tongue
Rocker
Mercury (tilt)
Sip/puff
Tread
Other________________________________________________________
Summary of Students Abilities and Concerns Related to Computer/Device Access
23

SECTION 2
Motor Aspects of Writing

1. Current Writing Ability (Check all that apply.)
Holds pencil, but does not write

Scribbles with a few recognizable letters
Uses pencil adapted with ___________________
Copies from book (near point)
Prints a few words
Prints name
Writes cursive
Writing is limited due to fatigue
Writing is slow and arduous
Pretend writes
Uses regular pencil
Copies simple shapes
Copies from board (far point)
Writes on 1" lines
Writes on narrow lines
Uses space correctly
Sizes writing to fit spaces
Writes independently and legibly
2. Assistive Technology Used (Check all that apply.)

Paper with heavier lines
Special pencil or marker
Computer
Paper with raised lines

Splint or pencil holder
Other
Pencil grip
Typewriter
3. Current Keyboarding Ability (Check all that apply.)
Does not currently type

Activates desired key on command
Types slowly, with one finger
Types slowly, with more than one finger
Accidentally hits unwanted keys
Performs 10 finger typing
Requires arm or wrist support to type
Accesses keyboard with head or mouth stick
Uses mini keyboard to reduce fatigue
Uses switch to access computer
Uses Touch Window
Uses alternative keyboard
Uses access software
Uses Morse code to access computer
Uses adapted or alternate keyboard, such as________________________________________________
Other_______________________________________________________________________________
4. Computer Use (Check all that apply.)
Has never used a computer

Uses computer at school
Uses computer at home
Uses computer for games
Uses computer for word processing
Uses computers spell checker
Uses computer for a variety of purposes, such as
Has potential to use computer but has not used a computer because
24

5. Computer Availability and Use
The student has access to the following computer(s)
PC
Macintosh
Desktop
Laptop
Location:
Other________________________________
The student uses a computer

Rarely Frequently Daily for one or more subjects or periods
Every day, all day
Summary of Students Abilities and Concerns Related to Writing
25

SECTION 3
Composing Written Material

1. Typical of Students Present Writing (Check all that apply.)
Short words
Sentences
Multi-paragraph reports
Short phrases
Paragraphs of 2-5 sentences
Other _________________
Complex phrases
Longer paragraphs
_______________________
2. Difficulties Currently Experienced by Student (Check all that apply.)
Answering questions
Getting started on a sentence or story
Adding information to a topic
Sequencing information
Integrating information from two or more sources
Relating information to specific topics

Determining when to begin a new paragraph
Generating ideas
Working w/peers to generate ideas and information
Planning content
Using a variety of vocabulary
Summarizing information
Other_________________________________
___________________________________
3. Strategies for Composing Written Materials Student Currently Utilizes (Check all that apply.)
Story starters
Preset choices or plot twists
Webbing/concept mapping
Outlines
Templates to provide the format or structure

(both paper and electronic)
Other_________________________________
4. Aids/Assistive Technology for Composing Written Materials Utilized by Student

(Check all that apply.)
Word cards
Word book
Word wall/word lists
Prewritten words on cards or labels
Dictionary
Electronic dictionary/spell checker
Whole words using software or hardware (e.g. IntelliKeys)
Symbol-based software for writing (e.g. Writing with Symbols 2000 or Pix Writer)
Word processing with spell checker/grammar checker
Talking word processing
Abbreviation/expansion
Word processing with writing support
Multimedia software
Voice recognition software
Other________________________________________________________________________________
Summary of Students Abilities and Concerns Related to Computer/Device Access
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SECTION 4
Communication
1. Students Present Means of Communication
(Check all that are used. Circle the primary method the student uses.)
Changes in breathing patterns
Facial expressions
Sign language approximations
Body position changes

Eye-gaze/eye movement
Gestures
Pointing
Sign language (Type____________________ # signs_______
# combinations _______ # signs in a combination _______)
Vocalizations, list examples

Vowels, vowel combinations, list examples
Single words, list examples & approx. #
Reliable no
Reliable yes
2-word utterances
3-word utterances
Semi intelligible speech, estimate % intelligible:____________
Communication board Tangibles Pictures Combination pictures/words
Voice output AC device (name of device)

Writing
Words
Intelligible speech
Other
2. Those Who Understand Students Communication Attempts (Check best descriptor.)

Strangers
Teachers/therapists
Peers
Siblings
Parent/Guardian
Most of the time
Part of the time
Rarely
Not Applicable
3. Current Level of Receptive Language

Age approximation _______
If formal tests used, name and scores
If formal testing is not used, please give an approximate age or developmental level of functioning. Explain your
rationale for this estimate.
4. Current Level of Expressive Language

Age approximation: _______
If formal tests used, name and scores
If formal testing is not used, please give an approximate age or developmental level of functioning. Explain your
rationale for this estimate.
27

5. Communication Interaction Skills
Desires to communicate
Yes No
To indicate yes and no the student
Shakes head
Signs
Vocalizes
Points to board
Uses word approximations
Gestures
Eye gazes
Does not respond consistently
Can a person unfamiliar with the student understand the response?
Yes
Turns toward speaker

Interacts with peers
Aware of listeners attention
Initiates interaction
Asks questions
Responds to communication interaction
Requests clarification from communication partner
Repairs communication breakdown
Requires frequent verbal prompts
Requires frequent physical prompts
Maintains communication exchange
Terminates communication
No
Always Frequently Occasionally
Seldom
Never
Describe techniques student uses for repair (e.g. keeps trying, changes message, points to first letter etc.).
6. Students Needs Related to Devices/Systems (Check all that apply.)
Walks
Uses wheelchair
Drops or throws things frequently
Needs device w/large number of words and phrases
Other
Carries device under 2 pounds

Needs digitized (human) speech
7. Pre-Reading and Reading Skills Related to Communication (Check all that apply.)
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
Object/picture recognition
Symbol recognition (tactile, Mayer-Johnson, Rebus, etc.)
Auditory discrimination of sounds
Auditory discrimination of words, phrases
Selecting initial letter of word
Following simple directions
Sight word recognition
Putting two symbols or words together to express an idea
28

8. Visual Abilities Related to Communication (Check all that apply.)
Maintains fixation on stationary object

Scans line of symbols left to right
Visually recognizes people
Visually recognizes photographs
Looks to right and left without moving head

Scans matrix of symbols in a grid
Visually recognizes common objects
Visually recognizes symbols or pictures
Needs additional space around symbol
Visually shifts horizontally
Visually shifts vertically
Recognizes line drawings
Is a specific type (brand) of symbols or pictures preferred?

What size symbols or pictures are preferred?
What line thickness of symbols is preferred?
inches
Does student seem to do better with black on white, or white on black, or a specific color combination for
figure/ground discrimination?
Explain anything else you think is significant about the responses the student currently uses or his/her need for
augmenting communication (Use an additional page if necessary)
Summary of Students Abilities and Concerns Related to Communication
29

SECTION 5
Reading
1. The Student Demonstrates the Following Literacy Skills. (Check all that apply.)
Engages in joint attention with adult caregiver to activities (e.g. songs, stories, games and/or toys)
Shows an interest in books and stories with adult
Shows and interest in looking at books independently
Associates pictures with spoken words when being read to
Realizes text conveys meaning when being read to
Recognizes connection between spoken words and specific text when being read to
Pretend writes and reads what he or she has written, even if scribbles
When asked to spell a word, gets first consonant correct, but not the rest of the word
Demonstrates sound manipulation skills including:
Initial and final sounds in words
Initial letter names/sounds
Recognizes, names and prints the alphabet (if motor skills are limited, may use alternative means rather than
printing to demonstrate knowledge of the alphabet)
When asked to spell a word, gets first and last sounds correct
Applies phonics rules when attempting to decode printed words
Sound blends words
Reads and understands words in context
Spells words using conventional spelling in situations other than memorized spelling tests
Reads and understands sentences
Composes sentences using nouns and verbs
Reads fluently with expression
Reads and understands paragraphs
Composes meaningful paragraphs using correct syntax and punctuation
2. Students Performance Is Improved by (Check all that apply.)
Smaller amount of text on page

Word wall to refer to
Graphics to communicate ideas
Bold type for main ideas
Additional time
Spoken text to accompany print
Other_____________________________________
Enlarged print
Pre-teaching concepts
Text rewritten at lower reading level
Reduced length of assignment
Being placed where there are few distractions
Color overlay (List color________________)
3. Reading Assistance Used

Please describe the non-technology based strategies and accommodations that have been used with this student
30

4. Assistive Technology Used
The following have been tried. (Check all that apply.)
Highlighter, marker, template, or other self-help aid in visual tracking
Colored overlay to change contrast between text and background
Tape recorder, taped text, or talking books to read along with text
Talking dictionary or talking spell checker to pronounce single words
Hand held scanner to pronounce difficult words or phrases
Computer with text to speech software to
Speak single words Speak sentences Speak paragraphs Read entire document
Explain what seemed to work about any of the above assistive technology that has been tried.
5. Approximate Age or Grade Level of Reading Skills

6. Cognitive Ability in General
Significantly below average
Average
Below average
Above average
7. Difficulty
Student has difficulty decoding the following. (Check all that apply.)
Reading Textbook
Subject Area Textbooks
Worksheets
Student has difficulty comprehending the following. (Check all that apply.)
Worksheets
Reading Textbook Subject Area Textbooks
Tests
Tests
8. Computer Availability and Use

The student has access to the following computer(s):
PC
Macintosh
9. The Student Uses a Computer:

Rarely
Frequently
For the following purposes
Daily for one or more subjects or periods Every day, most of the day
Summary of Students Abilities and Concerns Related to Reading
31

SECTION 6
Learning and Studying

1.
Difficulties Student Has Learning New Material or Studying (Check all that apply.)
Remembering assignments
Remembering steps of tasks or assignments
Finding place in textbooks
Taking notes during lectures
Organizing information/notes
Organizing materials for a report or paper
Turning in assignments
Other
Reviewing notes from lectures
2. Assistive Technology Tried (Check all that apply.)
Print or picture schedule

Low tech aids to find materials (e.g. index tabs, color coded folders)
Highlighting text (e.g. markers, highlight tape, ruler)
Recorded material
Voice output reminders for assignments, steps of task, etc.
Electronic organizers
Pagers/electronic reminders
Hand held scanner to read words or phrases
Software for manipulation of objects/concept development
Software for organization of ideas and studying
Palm computers
Other
3. Strategies Used
Please describe any adaptations or strategies that have been used to help this student with learning and studying.
Summary of Students Abilities and Concerns in the Area of Learning and Studying
32

SECTION 7
Math
1. Difficulties Student Has with Math (Check all that apply.)
Legibly writing numerals
Understanding meaning of numbers
Understanding money concepts
Completing multiplication and division
Understanding units of measurement
Creating graphs and tables
Understanding fractions
Converting to mixed numbers
Solving story problems
Graphing
Understanding and use of trigonometry functions
Other
Understanding math related language

Understanding place values
Completing simple addition and subtraction
Completing complex addition and subtraction
Understanding tables and graphs
Understanding time concepts
Working with fractions
Understanding decimals /percents
Understanding geometry
Understanding the use of formulas
Checking work
2. Assistive Technology Tried

Abacus
Math line
Talking calculator
Braille calculator
Enlarged math worksheets
Alternative keyboards (e.g., IntelliKeys)
Low-tech alternatives for answering

Recorded material
Voice output reminders for assignments, steps of task, etc.
Pagers/electronic reminders
Software for manipulation of objects/concept development
Talking or Braille watch
Palm computers
Other
Math Smart Chart

Tactile math devices (ruler, clock, etc.)
Electronic organizers
Single word scanners
On screen scanning calculator
Software for organization of ideas and studying
3. Strategies Used
Please describe any strategies that have been used to help.
Summary of Students Abilities and Concerns Related to Math
33

SECTION 8
Recreation and Leisure

1. Difficulties Student Experiences Participating in Recreation and Leisure (Check all that apply.)
Understanding cause and effect

Understanding turn taking
Handing/manipulating objects
Throwing/catching objects
Understanding rules
Waiting for his/her turn
Following simple directions
Following complex directions

Communicating with others
Hearing others
Seeing equipment or materials
Operating TV, VCR, etc.
Operating computer
Other
2. Activities Student Especially Enjoys
3. Adaptations Tried to Enhance Participation in Recreation and Leisure
How did they help?
4. Assistive Technology Tried (Check all that apply.)
Toys adapted with Velcro, magnets, handles etc.

Toys adapted for single switch operation
Adaptive sporting equipment, such as lighted or beeping ball
Universal cuff or strap to hold crayons, markers, etc.
Modified utensils, e.g. rubber stamps, rollers, brushes
Ergo Rest or other arm support
Electronic aids to control/operate TV, VCR, CD player, etc.
Software to complete art activities
Games on the computer
Other computer software
Other
Summary of Students Abilities and Concerns in the Area of Recreation and Leisure
34

SECTION 9
Seating and Positioning

1. Current Seating and Positioning of Student (Check all that apply.)
Sits in regular chair w/ feet on floor

Sits in regular chair w/ pelvic belt or foot rest
Sits in adapted chair
Sits in seat with adaptive cushion that allows needed movement
Sits in wheelchair part of day
Sits comfortably in wheelchair most of day
Wheelchair in process of being adapted to fit
Spends part of day out of chair due to prescribed positions
Spends part of day out of chair due to discomfort
Enjoys many positions throughout the day, based on activity
Has few opportunities for other positions
Uses regular desk
Uses desk with height adjusted
Uses tray on wheelchair for desktop
Uses adapted table
2. Description of Seating (Check all that apply.)

Seating provides trunk stability
Seating allows feet to be on floor or foot rest
Seating facilitates readiness to perform task
There are questions or concerns about the students seating
Student dislikes some positions, often indicates discomfort in the following positions
How is the discomfort communicated?
Student has difficulty using table or desk
There are concerns or questions about current wheelchair.
Student has difficulty achieving and maintaining head control, best position for head control is
Where are their hips?
Can maintain head control for ________ minutes in this position.
Summary of Students Abilities and Concerns Related to Seating and Positioning
35

SECTION 10
Mobility
1. Mobility (Check all that apply.)
Crawls, rolls, or creeps independently
Is pushed in manual wheelchair
Uses wheelchair for long distances only
Uses manual wheelchair independently
Is learning to use power wheelchair
Uses power wheelchair
Needs help to transfer in and out of wheelchair
Transfers independently
Has difficulty walking
Walks with assistance
Has difficulty walking up stairs
Has difficulty walking down stairs
Needs extra time to reach destination
Walks independently
Walks with appliance
Uses elevator key independently
2. Concerns About Mobility (Check all that apply.)
Student seems extremely tired after walking, requires a long time to recover
Student seems to be having more difficulty than in the past
Student complains about pain or discomfort
Changes in schedule require more time for travel
Changes in class location or building are making it more challenging to get around
Transition to new school will require consideration of mobility needs
Other
Summary of Students Abilities and Concerns Related to Mobility
36

Section 11
Vision
A vision specialist should be consulted to complete this section.
1. Date of Last Vision Report ____________________

Report indicates (please address any field loss, vision condition, etc.)
2. Visual Abilities (Check all that apply.)
Read standard textbook print

Read text if enlarged to (indicate size in inches)
Requires specialized lighting such as
Requires materials tilted at a certain angle (indicate angle)
Can read using optical aids, list:
Currently uses the following screen enlargement device
Currently uses the following screen enlargement software
Recognizes letters enlarged to ______ pt. type on computer screen
Recognizes letters enlarged to ______ pt. type for _______minutes without eye fatigue.
Prefers Black letters on white White on black ________________(color) on ____________
Tilts head when reading
Uses only one eye: Right eye Left eye
Uses screen reader:
Requires recorded material, text to speech, or Braille materials
3 Alternative Output
Currently uses (Check all that apply.)
Slate and stylus
Talking calculator
Braille calculator
Braille notetaker
Electric Brailler
Refreshable Braille display
Tactile images
Screen reader
Braille translation software:
37

Level of proficiency (Check the one that most closely describes the student.)
Requires frequent physical prompts
Needs only intermittent cues
Trouble-shoots problems related to device
Requires frequent verbal cues

Uses device to complete tasks independently
4. Writing/Handwritten Materials (check all that apply)
Writes using space correctly

Writes appropriate size
Reads someone elses writing
Reads cursive
Requires bold or raised-line paper
Requires colored pencils, pens, or paper
Writes on line
Reads own handwriting
Reads hand printing
Skips letters when copying
Requires softer lead pencils
Requires felt tip pen Thin point Thick point
Summary of Students Abilities and Concerns Related to Vision
38

SECTION 12
Hearing
A hearing specialist should be consulted to complete this section.
1. Audiological Information
Date of last audiological exam____________________
Hearing loss identified
Right Ear
Mild
Left Ear
Mild
Onset of hearing loss
Moderate
Moderate
Severe
Severe
Profound
Profound
Etiology
2. Unaided Auditory Abilities (Check all that apply.)
Attends to sounds
High pitch
Low pitch
Discriminates environmental vs. non-environmental sounds
Turns toward sound
Hears some speech sounds
Understands synthesized speech
Voices
Background noises
3. Students Eye Contact and Attention to Communication (Check best descriptor.)

Poor
Inconsistent
Limited
Good
Excellent
4. Communication Used by Others
Indicate the form of communication generally used by others in each of the following environments.
(Check all that apply.)
School
Home
Community
Body language
Tangible symbols
Gestures
Speech
Cued speech
Picture cues
Written messages
Signs and speech together
Signed English
Contact (Pidgin) sign language
American Sign Language (ASL)
5. Level of Receptive Proficiency in Each Environment

Understands single words
Understands short phrases
Understands majority of
communications
School
Home
Community
39

6. Student Communicates with Others Using (Check all that apply)
Speech
Signs and speech together
Signed English
Other_____________________
American Sign Language

Gestures
Picture cues
Level of expressive communication:

Single words
Combination of words
Body language
Written messages
Contact (Pidgin) sign language
Proficient
7. Is There a Discrepancy Between Receptive and Expressive Abilities?

Yes
No
If yes, describe further.
8. Services Currently Used (Check all that apply)

Audiology
Educational interpreter using:
Note taker
ASL
Transliterating
PSE
Oral
9. Equipment Currently Used (Check all that apply.)

Hearing aids
Cochlear implant
Telecaption decoder
Vibrotactile devices
Classroom amplification system
TTY/TDD
FM system
Other_________________________________________________
10. Present Concerns for Communication, Writing, and/or Educational Materials

Cannot hear teacher/other students
Cannot respond to emergency alarm
Cannot participate in class discussions
Cannot benefit from educational videos/programs
Displays rec./exp. language delays
Cannot use telephone to communicate
11. Current communication functioning (Check all that apply)
Desires to communicate
Initiates interaction
Responds to communication requests
Reads lips
Appears frustrated with current communication functioning
Requests clarification from communication partners (Would you please repeat that?)
Repairs communication breakdown (Keeps trying, changes message)
12. Current Reading Level

Summary of Hearing Abilities and Concerns
40

Section 13
General
Are there any behaviors (both positive and negative) that significantly impact the students
performance?
Are there significant factors about the students strengths, learning style, coping strategies or
interests that the team should consider?
Are there any other significant factors about the student that the team should consider?
Does student fatigue easily or experience a change in performance at different times of the day?
41

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WATI Assessment Package

Referral/Question Identification Guide

School Contact Person

Persons Completing Guide

Familys Primary Language

Students Primary Language

Significant Developmental Delay

Specific Learning Disability

Current Age Group

Current Service Providers

Medical Considerations (Check all that apply.)

Other Issues of Concern