Assistive Technology Tool Kit Sign Out Sheet

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Assistive Technology Tool Kit Sign Out Sheet
Please complete all sections of the form for each item borrowed.
BORROWER ___________________________ SCHOOL_________________
GRADE _________________
STUDENT ___________________________
Scale: Please apply the following rating scale in the Results section for each item borrowed.
1
2
3
4
Totally Ineffective
Somewhat Ineffective
Somewhat Effective
Totally Effective
(didn’t work at all; device
(but might work better with
(but could be even more so)
(i.e. purpose met)
clearly inappropriate)
further refinement training)
SIGN OUT
Student Task: ______________
AT
Date
Date
Results/Comments
_________________________________
#
Out
In
(1-4)
1
2
3
4
AT Item:
Student Task: ______________
1
2
3
4
_________________________________
AT Item:
Student Task: ______________
1
2
3
4
_________________________________
AT Item:

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