Report (Pre-Assessment, - University of Oregon
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DYNAMIC AAC EVALUATION PROTOCOL – PED or Adult with Developmental DisabilitiesStep I: Initial Client InformationPersonal InformationName of Person:Date of Birth:Pronouns:Place of Residence:Primary Medical Diagnosis:ICD-10 Code:Address:Speech/Language Diagnosis:ICD-10 Code:Date of Onset/Referral:Home Telephone:Email:Cell Phone:Advocate/Guardian:Telephone:Address:Cell Phone:Fax:Email:Physician Name:NPI #:Physician Phone:Date of last visit:Physician Fax:Address:Insurance Carrier:Medicaid #:Insurance ID #:Medicare #:Insurance Sponsor:Insurance Phone #:Assessment InformationDate(s) of Evaluation Sessions:Evaluation Site(s):Evaluation Team Members and Roles:Pre-Assessment ActivitiesReview the pre-assessment information prior to any formal on-site assessment activities.Pre-Assessment Form Sent pediatric | adult congenital | adult acquired Sent To:Date Sent:Address:Date Received Back:Additional Information Received:speech therapy reportoccupational therapy physical therapy reporteducational report/IEP/support planvideo/photographsTelephone:otherAssessment InterviewConduct an interview with available family/caregivers to confirm and/or clarify information from the pre-assessment form. Include the person who needs AAC. Complete any additional protocols, as needed. Record the interview.Confirm medical information:Confirm perceptual information:hearing:vision:tactile/proprioceptive/motor:information processing:Record current medications:Confirm history of speech therapy intervention:Confirm history of AAC system use:Confirm current status of AAC system use:AAC Needs Assessment (attach form):Additional protocols used:Social Networks: A Communication Inventory for Individuals with Complex Communication Needs and their Communication Partners. (Blackstone & Berg, Attainment Company)Test of Aided-Communication Symbol Performance (Bruno, Mayer-Johnson, LLC)The Communication Matrix (Rowland)The AAC Profile: A Continuum of Learning (Kovach, LinguiSystems)Checklist of Communication Competencies, Revised (Bloomberg, West, Johnson, and Iacono, 2009)Other:Step II: Sensory and Motor Report (Pre-Assessment, Caregiver) Informal Assessment Formal AssessmentPerceptual Skills for Use of an AAC SystemVisionUnaided and functional for AAC useCorrected (glasses/contacts) and functional for AAC useFunctional use of AAC system required vision accommodations (check necessary accommodations)Concerns regarding functional visual processing (cortical visual skills) in absence of acuity difficultyVision AccommodationsIncreased symbol sizeAuditory feedbackDecreased visual clutterIncreased font sizeColor ContrastFamiliar PhotographsAnimationPositioned at:Other:HearingUnaided and functional for AAC useHearing Aids L R Bilateraland functional for AAC useModifications needs (with/without hearing aids)Hearing AccommodationsIncreased volumeVisual cues (display of message, highlight on activation)HeadphonesDual display for communicationOther:Motor Skills for Access of an AAC SystemPositioning for AccessIs the person appropriately positioned in their wheelchair (or regular/special chair) for maximum function to access an AAC system? NA | yes | no If NO, need to consult an expert in positioning (PT or OT)Hand UseControl: Complete Partial NoFunctional Movement: Complete Partial NoHead UseControl: Complete Partial NoFunctional Movement: Complete Partial NoMotor Skills for Transportation of an AAC SystemCurrent Means of Mobility (check):Walks independentlyWalks with assistances/aidesCaneQuad caneWalkerManual wheelchair ( self-propelled or partner-dependent)Power wheelchair ( joystick head array sip and puff switch)*Is purchase of a power wheelchair anticipated in the near future? Yes | NoScooterAnticipated Transportation of an AAC SystemSelf-carried | Carried by others | Mounted on wheelchair | Attached to walker3. If Self-Carry: Have the person self-carry various AAC systems and observe balance, strength, and mobility in transporting the system. Manual communication board | Tablet-iPad | Dedicated SGD | ComputerIf mounting on a wheelchair:Brand of wheelchair:Tube width/size:Lap tray size:Step III: Speech and Language Status Report (Pre-Assessment, Caregiver) Informal Assessment Formal AssessmentFormal Tests Administered and Results (SIT, PPVT, EOWPVT, etc):Speech Intelligibility: _____ Non-speaking_____% intelligible with familiar listeners _____% intelligible with unfamiliar listeners 1. The person is aware when speech is not understood? yes | no | maybe | don’t know2. The person is showing signs of communication frustration when depending on their speech to communicate? yes | no | maybe | don’t know Describe:3. What strategies does the person use to help communication partners understand their speech? ? repeats? slows down? adds gestures/signs/pointing? spells initial letters for misunderstood words? uses a related word/concept? other:Receptive Language Abilities No deficits in comprehensionSubjective Comprehension Checklist Single words Phrases Sentences Conversation 1-step direction 2-step direction Multiple-step direction Yes/No questions Choice questions Wh-questions Symbols: Symbols, Photos, Line drawings, Written word(s)?Test of Aided Symbol Performance (TASP)Receptive Symbols (Concrete)PercentageReceptive Symbols (Abstract)PercentageVerbsVerbsPeoplePronounsLocationsPrepositionsAdj/AdvArticlesCategorizationSubordinateGrammatical AuditoryGrammatical VisualCategory Closure Expressive Language AbilitiesUnintentional behaviors (yelling, pinching, kicking, throwing) are primary means for people to interpret feelings and needs? yes | no If yes:Behavior:Interpreted Meaning:Expressive Communication Checklist (Communication Matrix)PreIntentional Behavior (Behavior reflects state but isn’t on purpose to get response) Facial Expression Crying LaughingIntentional Behavior (Purposeful but not necessarily communicative) Reaching for something Eye gaze Protesting with voice, body movementUnconventional gestures Gestures Pulling on people Vocalizing Eye gaze Conventional Gestures Pointing Nodding Shaking Head Looking at partner to item/activity + backConcrete Symbols Objects/Pictures Iconic gestures (gesturing “come here” or patting seat)Abstract Symbols Formal signs Symbols/printed words Communication at word levelLanguage Putting words/abstract symbols together to form phrasesMLU:TASP Syntactic Performance Message Form MLU: S V OBJ ART ADJ/ADVLanguage Sample in Picture Description Task:Functions of Communication Observed/Reported: Requesting to meet wants and needs Refusing/Protesting Sharing information (specific news, labeling, responding, commenting, offering opinion (“like it”, “yucky”) Requesting information (“who’s that?” “what’s next?” “where?” “when are we done?”) Social etiquette (greetings, polite forms)Written LanguageProduces by handwritingProduces by typingGiven single words (with or without symbols), produces N/A N/A N/A Letter Letter 2-3 word phrases Words (copying) Words (copying) Simple sentences Words (independently) Words (independently) Complex sentences Sentences Sentences Paragraphs Paragraphs Adaptations for Typing Standard keyboard ABC keyboard Writing tool adapted Spelling on device QWERTY keyboard Word prediction supportReadingFunctional Reading ComprehensionReading Comprehension Level Nothing Age-appropriate (at grade level) Sight words only Below age level (grade level) SentencesApproximate Grade Level: ParagraphsSocial & Strategic Communication SkillsCommunication Skill:YESNOSeeks the attention of others for the purpose of communication?Engages in joint attention with a communication partner?Responds to the communication of others?Initiates communication with others? Stays on topic during conversations? Takes turns in a conversation? Attempts to repair communication breakdowns? Switches between communication strategies, as needed? Alternates message length/style based on communication partner and communication situation? CognitionRepresentational SkillsThe person understands the need and/or value of using an AAC system. immediately (describe): limited, but teachable (describe):The person can use these ways to represent vocabulary: manual signs/gestures objects photographs of people, places, things pictures for words that are picture producers (e.g., house, car, apple, shoe) pictures for words that are NOT picture producers (e.g., safe, live, inside) printed letters printed wordsThe person identifies pictures when: 1 picture means 1 thing (picture of a house = house) 1 picture means more than 1 thing (e.g., house = house, home, live, inside) 1 picture represents a semantic category (e.g., house = buildings) 1 picture represents a grammatical category of words (e.g., bridge = prepositions)Learning: Demonstrated new learning during this evaluation (e.g., new techniques, devices)? yes | no Describe: Informal Assessment:Memory for tasks presented:Attention to tasks presented: within functional limits within functional limits partially limited partially limited severely limited severely limitedCommunication Competence (AAC Profile: A Continuum of Learning)SubtestCurrent Skill Set Desired Skill Set OperationalLinguisticSocialStrategicSummary of Speech and Language Status Emergent/Functional Difficult to fully assess receptive languageBeginning to communicate using a variety of methods (gestures, body language, facial expressions, simple symbols) Requires assistance from the communication partnerCommunicates a limited number of messages in a small set of specific contexts or routines Context Dependent/SituationalUnderstands simple and clear symbols; beginning to understand more abstract symbolsUnderstands most communication about things that are present. May misunderstand references to people, situations and items that are not presentCommunicates effectively in a limited number of situations OR communicates in a limited way across a variety of situationsOverall ability to communicate effectively depends on the environment, topic or communication partnerHas very limited ability to creatively combine symbols to create new messagesLimited literacy skills Independent/CreativeAge appropriate receptive languageFollows the linguistic rules appropriate for his/her ageWrites and spells at or near age levelAble to combine single words, spelling, and phrases together to create novel and flexible messages about variety of subjects. Continuum of Communication Competence model by Patricia Dowden Step IV: Current Communication NeedsEnvironments: Check all the client participates in Home/Residence Telephone School Community Work Support Group Medical Facility Other: Face-to-Face Other:Partners: Check all partners with whom client interacts Immediate Family Medical professionals Extended Family Home health assistants/caregiver Friends Individuals in community Peers Other: Teachers Other: Residential Staff Other:Topics: Check all topics about which the client needs to communicate Activities of Daily Living (ADLs) Medical Needs Medical/Personal/Legal Decision-making Emergency needs/information Personal needs Personal information Other:Functions: Ask questions Respond to questions Social interaction (family and community) Social etiquette Resolve/prevent communication breakdowns Other:Summary and Prognosis: Choose one of the following Daily functional communication needs cannot be met using natural speech or low-tech/no-tech augmentative communication techniquesOR Improvements in the quantity and intelligibility of client’s speech are unlikely, possible, expected at this time. At this time, verbal skills do not allow them to meet all of their daily communication needs nor do they allow them to continue to develop/ regain age-appropriate language skills.OR Client has a degenerative condition for which tradition speech/language therapy is not effective. Their natural speech does not allow them to meet the majority of their daily communication needs.From Funding Manager, Tobii-Dynavox Prognosis for functional use of an augmentative communication system: Excellent Good FairStep V: Hands-On Trials and ResultsRequired FeaturesRequired featuresLanguage Message generation via spelling (language structure) Message generation via combinations of single words (language structure) Message generation via pre-stored messages (language use) Combination of message generation modes for quick communication and creation of novel messages (language use and language structure) Variety of symbols to represent words or concepts Ability to use digital photos to represent words or concepts Ability to use scenes to set the context for communication Word, character, and phrase prediction to speed rate of communication or decrease effort when spelling Other:Access Carrying case for protection while device is being transported and used Wheelchair mounting system for easy and safe access in all environments Desk mount for access at various tabletops Standard size keyboard for touch typing to optimize communication speed Keyboard to allow for exploration and literacy learning Keyboard to allow for spelling of novel messages Multiple keyboard layouts Adjustment of access settings (e.g. hold time, scanning speed) to best meet need Accessible via direct selection Accessible via eye gaze Accessible via mouse or mouse alternative (e.g. trackball, Head Mouse, Tracker) Accessible via joystick Accessible via one- or two- switch scanning Accessible via Morse code Accessible via multiple modes to accommodate for changes in condition over time Other:Device Characteristics Portability for use in multiple environments Durability to withstand daily use Battery power to allow for use throughout the day Voice output for communication in all environments Synthesized speech for production of novel messages Feedback (e.g. button click, message window highlight) to assist in message preparation/selection Dual display for interactions with hearing impaired individuals or in noisy environments Flexible font size and color for clearest visual presentation Flexible number and size of messages per page for optimal ease of use and comprehension Ability to save, retrieve, and edit longer files for use during story telling, speeches, and caregiver direction Other:Connections to the world Telephone access to allow for communication of emergency information Control of electronic appliances (e.g. lights, fan) for increased independence Email/texting capability for interaction with community (medical appointments, information, vocational interactions, etc) Internet accessibility for interaction with community (medical appointments, information, vocational interactions, etc) Other:Step VI: ASSESSMENT OF SPECIFIC EQUIPMENT AND TECHNIQUES- Use one form per device trialed.Fill in details, check items patient can accomplish, mark N/A for features not available on this device, and X for features not useable by this patientDevice/Software/Materials: ______________________________________Trial SpecificsLength of trial: Considered but rejected without trial due to: Inability to meet required features Lack of symbols to represent language Lack of voice output Limited ability to meet comm needs Weight or size limiting portability Other: Small size not meeting physical or visual needs Trial during evaluation session: Longer trial (>1 week) for ___________________Additional info:Techniques to elicit communication: Discussion Response to Questions Role play Functional Activity (snacks, activities, mobility) Play with motivating items (videos, toys, magazines, books) Other (describe):Care for AAC SystemIndependentPartner AssistedPartner DependentTransportation (carrying)Battery/Charger MaintenanceTurn on/offProgramming modsVolume ControlSize of Display: Hand-held (5”-7”) Tablet sized (10”) Large screen (12”) Extra large screen (15”)Size of Symbols: Keyboard 1” 2” >3”Access Methods: (consider physical, sensory, behavioral and attention skills/needs) Direct Selection with Touch with touch enter delay, with touch exit delay (to decrease accidental activation or repetitive tapping) Keyguard Configuration: _____ # locations _____ touch indicator (thin borders between buttons) _____ keyguard (wider border between buttons) _____ touch guide (small openings, i.e. circles, with larger covered space between buttons) Movement ConsiderationsSufficient on LeftSufficient on RightSufficient BilaterallyROMAccuracy Eye Tracking/Eye Gaze:Selection via: Blink DwellHold Time: _______ Seconds Zoom Highlight Border Highlight Inversion HighlightAudio Feedback Click: yes I noCalibration: both eyes left eye right eye Joystick/Mouse: Selection via: Pause External Switch Fire (joystick only) Zoom Highlight Border Highlight Inversion HighlightAudio Feedback: voice selection _____________________________ Private Speaker Output Device Speaker Output at _________ volumeSpeed: ________________ Scanning: Scan Type: Automatic Scanning with Single Switch Single Switch with Dwell Select with _____ second hold to select 2-Switch (switch to move scan target + switch to selectScanning Cues: Zoom Highlight Border Highlight Inversion Highlight Audio Scan Cue: voice selection _____________________ Private Speaker Output Device Speaker Output at ______ volumeScan Pattern: Row/Column Column/Row Left/Right Left/Center/Right Six Zones Linear Top/BottomSwitches Trialed: Mechanical button style Mechanical pad styleSwitch Control Site on Body:Position of input (position of switch):Targeting Method Accuracy: Independent Partner Support EmergingBody Position Considerations:Access Trials:Size of buttons reliably accessedNumber of buttons reliably accessedSize of screenQuadrants reliably accessedCognitive AccessSize of Symbols: Keyboard 1” 2” >3”Navigation: Single page, no navigation Can navigate – list pages:_____________Navigation Support: Independent Verbal prompts Taught in context Repetition Hand over hand Visual cue- button shape, highlight Partner assisted navigation Type of symbol: Object Photograph Symbol Word SpellingPage Format: Grid Free form SceneScan Pattern: Generative/Creative Word Based (e.g. Gateway, Word Power) Context Based (scenes or grids relating to particular settings Activity Based (scenes or grids relating to specific activities Pragmatically Organized (fxn- ex: want something, greetings, something’s wrong) Quick Messages (yes/no, hi/bye, let me/you do it, more/all done, good/bad) Social and Control Messages (greetings, needs, feelings, questions)Number of symbols on page: 1 2-4 8-11 12-15 20-30 40 60 >60Message Unit: Sentence Word Phrase LetterMean 1 word 2 words 3-5 words using a carrier phrase only >3 words Length Ex: I want, I see, I go, I like independently combined of Utterance on single page on single page (MLU): with navigation to other pgs with navigation to other pgsFunctions: Request Respond Comment Share info Reject Social exchange EscapeVocab expansion: Multiple levels Dynamic display EncodingEditing Functions: Close popup Delete Clear messageRate: Word prediction Abbreviation expansion Pre-stored messagesTrial 1: ________________________________________Conclusion: Most appropriate device at this time Meets some needs, but will continue looking for the following reasons: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Trial 2: ________________________________________Conclusion: Most appropriate device at this time Meets some needs, but will continue looking for the following reasons: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Trial 3: ________________________________________Conclusion: Most appropriate device at this time Meets some needs, but will continue looking for the following reasons: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ Step VII: Post-Evaluation Recommendations and Follow-Up Planning (Summary and Recommendations)SGD AND ACCESSORIES RECOMMENDED Check recommended device and accessories: DEVICETobii Dynavox I-110Prentke Romich Accent 800Saltillo NovaChat 10Tobii Dynavox IndiPrentke Romich Accent 1000Saltillo NovaChat 12Tobii Dynavox I12Prentke Romich Accent 1200Saltillo Chat FusionTobii Dynavox I15Saltillo NovaChat 8Other:TABLET APPLICATIONS: Comprehensive (core, context-based, dictionary, added features)Aacorn AACPRC LAMPTobii Dynavox CompassAutismateProloquo2Go CORE updateTobii Dynavox Snap+CoreAvaz TogetherSpeak4YourselfTouchChatGoTalk NowSpeech Hero AACOther:TABLET APPLICATIONS: Limited (one type of vocab organization)ChatAbleSomething to SaySo Much to SayMy First AACSonoFlexTalking CardsScene&HeardOther:SWITCHMechanical Button Big Button Microlight Plate Switch Cap Switch Cup Switch Mini CupSquare Pad Pillow Trigger Switch Switch Joystick with Push Mini Joystick SCATIR Other:ACCESS ACCESSORYExtra Charger Head Mouse Tracker Headpointer Eye Gaze Camera:____________________ Keygurd/guide:______________________ Other:MOUNTING AND PORTABILITYSwitch mount:_______________________ Tubing size:________________________” Other mounting placement:____________ Mount Brand:_______________________SGD Mount:________________________ Tubing Size:________________________” Other mounting placement:____________ Mount Brand:_______________________Standard Carrying CareAccessible Carrying CaseDurable Carrying CaseTreatment Plan and Follow UpINTERVENTION SCHEDULERecommended Follow-Up: Consultation as Needed Limited number of follow-up treatment sessions after receipt of device: _____(#) Ongoing therapy with ______ minutes per session; ______ # of sessions per week Individual therapy recommended Group treatment recommendedIf follow up services are not available, a high tech speech generating device is not recommendedTREATMENT GOALS: See Dynamic AAC Goals Grid and Planning Guide (DAGG-2) The Goals Grid should be completed to determine areas of strength and need. Partners should be consulted regarding priority goals targeting increasing function and independence.PATIENT/FAMILY SUPPORT OF SGDResponsible PartiesPatientFamilyCaregiver (Name) __________Manufacturer Rep (Name) ___________Therapist (Name) __________Other (Name) _________Therapy to address goalsInitial TrainingInitial Customization (programming, vocab selection, intervention planning)Ongoing Training and ModificationMaintenance of DeviceWarranty Maintenance ManagementNECESSARY FUNDING PAPERWORKCheck when obtainedDateMedicaid/Insurance Cards CopiedBenefits Assignment Signed by Caregiver/ConsumerDoctor’s PrescriptionAAC Evaluation WrittenQuote from ManufacturerResources/References Consulted: "AAC Report Coach - AACFundingHelp." AAC Report Coach - AACFundingHelp. N.p., n.d. Web. 07 Sept. 2015. <;. “Augmentative Communication Evaluation Summary,” Georgia Project for Assistive Technology, forms accessed on-line at Bruno, Joan. “Test of Aided Symbol Performance.” Mayer-Johnson, Pittsburgh, PA 2010 Clarke, Vicki and Holly Schneider. “Dynamic AAC Goals Grid-2” Published by Tobii Dynavox on-line. 2015. Accessed at aac-goals-grid-2-dagg-2.pdf. Dowden, Patricia. "Continuum of Communication Independence." UW Augcomm: Continuum of Communication Independence. University of Washington, Seattle, n.d. Web. 07 Sept. 2015. <; Korsten, Jane Edgar, Terry Vernon Foss, and Lisa Mayor Berry. "EMC, Inc. Home." EMC, Inc. Home. N.p., n.d. Web. 07 Sept. 2015. <; Rowland, Charity. "Communication Assessment for Parents & Professionals." Communication Matrix. Child Development and Resource Center, n.d. Web. 07 Sept. 2015. <; Shannon, Molly and Tammy Pereboom, “Augmentative Communication- How Do Pediatric Occupational and Physical Therapists Fit In?” North Carolina Assistive Technology Project. Powerpoint accessed on- line via resources/aac_for_ot_and_pt_4.28.pp The Funding Manager software, copyright 2008, Dynavox Technologies, Pittsburgh, PA ................
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