VIDBE-Q Volume 69 Issue 4
Figure 1
Sample Written Implementation Plan Form
Sample Assistive Technology Implementation Form
Student Information
Student: __________________
Date: __________________
Grade: __________________
Areas of
Difficulty:
Baseline Level of Function (PLEPS): Projected Outcomes
(Targeted Goals):
Implementation Team Members
Case Manager – __________________ Parent – __________________
Teacher of Students with Visual Impairment
(TSVI) – __________________
General Educator– __________________
Assistive Technology Specialist (AT) –
__________________
General Educator– __________________
General Educator– __________________ General Educator– __________________
Other – __________________ Administrator - __________________
Assistive Technology
Equipment and Software
Used
Status Task
Training
Training Module
Date
Person Trained and
Initials
Classroom Implementation
Action Steps
Required to Achieve
Outcomes:
Team Member
Responsible:
Projected Timelines: Review Date
and
Progress:
