FORM 14-3.

Augmentative and Alternative Communication Information

and Needs Assessment

Name: ___________________________________________ Age:__________ Date:_________________

Examiner’s Name:________________________________________________________________________
Informants: Relationship to Client:
_____________________________________ ____________________________________________
_____________________________________ ____________________________________________
_____________________________________ ____________________________________________

Instructions: For each modality ask the informant (1) whether the modality is used, and if it is to describe
the client’s current use of the modality, (2) to indicate the size of the client’s vocabulary using the modality,
and (3) to indicate how well the client is understood when using the modality. Use the spaces provided to
record notes.

Modality Description Vocabulary Size Intelligibility

Speech

Vocalizations

Sign language

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Modality Description Vocabulary Size Intelligibility

Gesture/pointing

Head nods

Eye gaze

Facial expressions

AAC device

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Modality Description Vocabulary Size Intelligibility

Other

Past AAC Experience

Instructions: Ask the informant the following questions. Record notes in the spaces provided.
Has this individual ever used a picture or letter-based AAC device in the past? If yes, describe the system.
Name of device: ________________________________ Length of time used:________________________
Number of symbols: _____________________________ Size of symbols:___________________________
Symbol system used: ____________________________ Organization of symbols:____________________
Access method: __________________________________________________________________________

What were the strengths and limitations of the AAC system described above?

Communication Environments

Instructions: Ask the informant to describe how the AAC will be used and with whom. Also determine
barriers to using the AAC. Take notes in the spaces provided.

Environment Description Interaction Partner

Home

School

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Environment Description Interaction Partner

Work

Community

Other

What barriers to AAC implementation exist in any of the environments listed above?

Mobility and Access

Instructions: Ask the informant to describe the client’s mobility and access regarding use of an AAC
system. Also determine specific mobility, seating, or positioning concerns.
Mobility Description Environment Used

Fully ambulatory

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Mobility Description Environment Used

Ambulatory with assistance

Manual wheelchair

Power wheelchair

Other

Are there any mobility, seating, or positioning concerns that will affect the implementation of an AAC
-system? If yes, describe.

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Functional Access Description Access Limitations

Left arm/hand

Right arm/hand

Head

Left leg/foot

Right leg/foot

Eye gaze

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Functional Access Description Access Limitations

Other

Other Technologies

Instructions: Ask the informant what other technologies will need to be integrated with an AAC system.
Record notes in the spaces provided.

Technology Description Environment Used

Wheelchair

Computer

Environmental controls

Switch toys

(continues)

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.
 FORM 14-3. Continued

Technology Description Environment Used

Other

AAC Expectations

What goals could be achieved if the client had access to an AAC system?

Adapted from Handbook of Augmentative and Alternative Communication (pp. 157–159), by S. L. Giennen and D. C.
DeCoste, 1997, Clifton Park, NY: Delmar Cengage Learning. Permission to reproduce for clinical use granted.