Accommodations Survey for Student Name

	A	B	C	D	E	F	G	H	I	J	K	L	M	N	O	P	Q	R	S	T	U	V	W	X	Y	Z	AA	AB	AC	AD	AE	AF	AG	AH	AI	AJ	AK	AL	AM	AN	AO	AP
1	Timestamp	Person Completing Form	Relationship to student:	Large Print	Magnification Devices	Sign Language	Braille	Audiotape, Compact Disk or other recording devices.	Tactile Graphics	Human Reader	Books on Tape or CDs	Recorded Books	Audio Amplification Devices	DVDs	Descriptive Video	Screen Reader	Talking Materials	Other presentation accommodations	If you marked Yes, please describe other Presentation Accommodations.	Scribe	Word Processor or Computer	Brailler	Note Takers	Tape Recorder	Speech to Text	Word Lists, math and science formulas, etc.	Calculation Devices	Visual Organizers	Multiple or Frequent Breaks	Spelling and Grammer Devices	Graphic Organizers	Other Response Accommodations	Reduce Distractions to student	If you marked Yes, please describe other Response Accommodations.	Reduce Distractions to Others	Change Locations	Other Setting Accommodations	Extended Time	Change Schedule or Order of Activities	Other Timing or Scheduling Accommodations	If you marked Yes, please describe other Setting Accommodations.	If you marked Yes, please describe other Setting Accommodations.

2	2/23/2012 12:20:51	Test 1	Student	No	No	No	No	No	No	Yes	Yes	Yes	No	Yes	No	No	No	No		Yes	Yes	No	Yes	No	No	Yes	Yes	No	Yes	No	No	No	No		No	No	No	Yes	No	No
3	2/23/2012 14:07:19	Test 2	Parent	No	No	No	No	Yes	No	Yes	Yes	Yes	No	No	No	Yes	No	No		Yes	No	No	Yes	No	No	No	No	Yes	No	No	Yes	No	Yes		No	No	No	Yes	No	No
4	2/23/2012 14:13:26	Test 3	Parent	No	No	No	No	No	No	No	Yes	No	No	Yes	No	Yes	No	No		No	Yes	No	No	Yes	No	Yes	Yes	No	Yes	Yes	No	No	No		No	No	No	Yes	No	No
5	2/23/2012 14:15:59	Test 4	General Education Teacher	No	No	No	No	No	No	No	No	No	No	No	No	No	No	No		No	No	No	No	No	No	No	No	No	No	No	No	No	No		No	No	No	No	No	No
6	2/23/2012 14:19:06	Test 5	General Education Teacher	No	No	No	No	No	No	No	No	Yes	No	Yes	No	Yes	No	No		No	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	No	No	No		Yes	No	No	No	Yes	No
7	2/23/2012 15:50:51	Test 6	Special Education Teacher	No	No	No	No	No	No	No	No	Yes	No	Yes	No	Yes	No	No		No	Yes	No	No	No	Yes	Yes	Yes	No	No	Yes	Yes	No	Yes		No	Yes	No	No	Yes	No
8	2/23/2012 15:57:14	Test 7	Paraprofessional	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Test	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	test	Yes	Yes	Yes	Yes	Yes	Yes	test	test
9	2/23/2012 16:00:50	Test 8	Counselor	No	Yes	No	Yes	No	Yes	No	Yes	No	Yes	Yes	No	No	Yes	No		Yes	No	No	Yes	No	No	Yes	No	Yes	No	No	No	No	Yes		Yes	Yes	No	Yes	No	No
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