Accommodations Survey for Student Name
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TimestampPerson Completing FormRelationship to student:Large PrintMagnification DevicesSign LanguageBrailleAudiotape, Compact Disk or other recording devices.Tactile GraphicsHuman ReaderBooks on Tape or CDsRecorded BooksAudio Amplification DevicesDVDsDescriptive VideoScreen ReaderTalking MaterialsOther presentation accommodationsIf you marked Yes, please describe other Presentation Accommodations.ScribeWord Processor or ComputerBraillerNote TakersTape RecorderSpeech to TextWord Lists, math and science formulas, etc.Calculation DevicesVisual OrganizersMultiple or Frequent BreaksSpelling and Grammer DevicesGraphic OrganizersOther Response AccommodationsReduce Distractions to studentIf you marked Yes, please describe other Response Accommodations.Reduce Distractions to OthersChange LocationsOther Setting AccommodationsExtended TimeChange Schedule or Order of ActivitiesOther Timing or Scheduling AccommodationsIf you marked Yes, please describe other Setting Accommodations.If you marked Yes, please describe other Setting Accommodations.
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2/23/2012 12:20:51Test 1StudentNoNoNoNoNoNoYesYesYesNoYesNoNoNoNoYesYesNoYesNoNoYesYesNoYesNoNoNoNoNoNoNoYesNoNo
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2/23/2012 14:07:19Test 2ParentNoNoNoNoYesNoYesYesYesNoNoNoYesNoNoYesNoNoYesNoNoNoNoYesNoNoYesNoYesNoNoNoYesNoNo
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2/23/2012 14:13:26Test 3ParentNoNoNoNoNoNoNoYesNoNoYesNoYesNoNoNoYesNoNoYesNoYesYesNoYesYesNoNoNoNoNoNoYesNoNo
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2/23/2012 14:15:59Test 4General Education TeacherNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNoNo
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2/23/2012 14:19:06Test 5General Education TeacherNoNoNoNoNoNoNoNoYesNoYesNoYesNoNoNoYesNoNoNoYesYesYesNoNoYesNoNoNoYesNoNoNoYesNo
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2/23/2012 15:50:51Test 6Special Education TeacherNoNoNoNoNoNoNoNoYesNoYesNoYesNoNoNoYesNoNoNoYesYesYesNoNoYesYesNoYesNoYesNoNoYesNo
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2/23/2012 15:57:14Test 7ParaprofessionalYesYesYesYesYesYesYesYesYesYesYesYesYesYesYesTestYesYesYesYesYesYesYesYesYesYesYesYesYesYestestYesYesYesYesYesYestesttest
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2/23/2012 16:00:50Test 8CounselorNoYesNoYesNoYesNoYesNoYesYesNoNoYesNoYesNoNoYesNoNoYesNoYesNoNoNoNoYesYesYesNoYesNoNo
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