"Assistive Technology and Accommodation(S) Assessment Form" - Delaware

This printable "Assistive Technology and Accommodation(S) Assessment Form" is a document issued by the Delaware Department of Labor specifically for Delaware residents.

Download a PDF of the latest edition of the form down below or find it through the department's forms library.

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Download "Assistive Technology and Accommodation(S) Assessment Form" - Delaware

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Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
Assistive Technology and Accommodation(s)
Assessment
(Must Accompany DVR – 7 Authorization in Order to Receive Payment)
Name of Consumer:
DOB:
Vendor, Person Completing Form:
DVR Counselor:
Assessment of functional limitations during the assessment process:
Functional Limitation
Yes
No
Difficulty in interpreting information
Limitations in sight
Limitations in hearing
Susceptibility to fainting dizziness, and
seizures
Incoordination
Stamina limitations
Head movement limitations
Sensation limitations
Difficulties in lifting, bending,
reaching and carrying
Difficulty in manual dexterity and
manipulation
Inability to use the upper extremities
Difficulty in sitting
Difficulty or inability to use the lower
extremites
Poor balance
Cognitive limitations
Emotional limitations
Limitations due to disfigurement
Substance abuse
Pain limitations
Department of Labor
DIVISION OF VOCATIONAL REHABILITATION
Assistive Technology and Accommodation(s)
Assessment
(Must Accompany DVR – 7 Authorization in Order to Receive Payment)
Name of Consumer:
DOB:
Vendor, Person Completing Form:
DVR Counselor:
Assessment of functional limitations during the assessment process:
Functional Limitation
Yes
No
Difficulty in interpreting information
Limitations in sight
Limitations in hearing
Susceptibility to fainting dizziness, and
seizures
Incoordination
Stamina limitations
Head movement limitations
Sensation limitations
Difficulties in lifting, bending,
reaching and carrying
Difficulty in manual dexterity and
manipulation
Inability to use the upper extremities
Difficulty in sitting
Difficulty or inability to use the lower
extremites
Poor balance
Cognitive limitations
Emotional limitations
Limitations due to disfigurement
Substance abuse
Pain limitations
Please describe the extent of the functional limitation(s) marked above (extent,
duration, intensity, frequency etc.):
Recommendations (Please list any accommodations or assistive technology
recommended along with a description as to how it will address the consumer’s
functional limitation(s):
Questions to Be Addressed (If marked as No, please describe):
1. Was the consumer an active part of the accommodation and assistive technology
evaluation and selection processes?
Yes
No
2. Do the equipment/accommodations recommended take advantage of the consumer's
unique abilities, capabilities and strengths?
Yes
No
3. Was a simple, minimal-cost solution found or considered?
Yes
No
4. Is the solution applicable a variety of assignments or tasks?
Yes
No
5. Were all accommodations requested truly “reasonable?”
Yes
No
Consumer Input:
Date(s) and Time(s) of Assessment:
Location(s) of Assessment:
Total Hours:
Consumer Signature
Date
Provider Signature (Sign and Print)
Date
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