NATRI Briefing Book: Critical Incident Report: Effective Incident Report

		Briefing Book Critical Incidents SurveyEffective Incident Report Reporting an Effective Incident Please answer each question then click SUBMIT to send your report. To protect rights to privacy, do not use identifiable names. Space is available at the end to provide additional comments. Any question marked by an asterisk is required. Table of Contents The Incident Report Use of Assistive Technology Devices Descriptive Information Comments Contact SECTION 1: The Incident Report Click the radio button in front of the functional area in which the assistive technology incident occurred:* Existence Functions needed to sustain life; Examples: eating, grooming,dressing, elimination, sleeping, hygiene... Communication Functions needed to receive, internalize, and express information and to interact socially; Examples: oral and written expression, visual and auditory reception, social discourse... Body Support, Protection, & Positioning Functions needed to stabilize, support, or protect a portion of the body; Examples: standing, sitting, alignment, stabilizing, preventing injuries... Travel & Mobility Functions needed to move horizontally or vertically; Examples: crawling, walking, using stairs, lateral and vertical transfers, navigating... Environmental interaction Functions needed to perform activities across environments; Examples: operating equipment, accessing facilities... Sports, Fitness, & Recreation Functions needed to participate in individual and group sports, leisure activities, and exercise; Examples: playtime, hobbies, sports, physical conditioning, games, craft activities... Education, Transition, & Rehabilitation Functions needed to participate in learning activities and to prepare for new school settings or post-school environments; Examples: educational assessment, learning, access to the general curriculum, creative and performing arts, using instructional materials, developing job skills, preparing for life after graduation... Description of the Incident Describe a time that you provided, or observed someone else provide, assistive technology devices or services in an EFFECTIVE way to a student with disabilities, or to someone who works with that student. The result of such action should have had a positive effect on the following general aim: When providing assistive technology devices or services, the general aim is to enable students with disabilities to improve their ability to function in the environment. Approximately how long ago did this incident happen?* What specific circumstances led up to this EFFECTIVE incident?* Exactly what did you, or the person(s) you observed, do in this EFFECTIVE incident?* What OUTCOME(S) made you believe that this was an EFFECTIVE action?* SECTION 2: Use of Assistive Technology Devices Did the incident you reported involve the use of an assistive technology device?* Yes No [If you answered "NO", go ahead to Section 3] What was the name and/or type of the device? Had the person used this device previously? Yes No Unsure Approximately how many months had the assistive device been used? To what extent was the user involved in making decisions about the selection of the device? Unable to participate Unknown Not involved Somewhat involved Very involved Approximately how many days did the user try out the device prior to its acquisition for long-term use? To what extent was training about the operation of the device provided to the user? Unknown No training Basic operation Comprehensive training To what extent was training about the operation of the device provided to those who worked with the user? Unknown No training Basic operation Comprehensive training To what extent was training about the operation of the device provided to members of the consumer's family? Unknown No training Basic operation Comprehensive training Did the action you reported in the incident facilitate continued use of the device by the user? Yes No Unsure SECTION 3: Descriptive Information What is your occupation?* Where did this incident occur? City and State:* Disability of assistive technology consumer:* Approximate age of assistive technology consumer:* Did this incident happen to you as a consumer of assistive technology devices or services?* Yes No In what setting did this incident occur?* School Agency Clinic Job Site Community Setting Home Other If Other, describe: Who was providing the assistive technology service?* Special Education Teacher General Education Teacher Speech/Language Pathologist Occupational Therapist Physical Therapist Assistive Technology Specialist Rehabilitation Counselor Rehabilitation Engineer School Psychologist Administrator Supervisor Classroom Assistant Therapy Assistant Technology Vendor Parent Other If Other, describe: What type of assistive technology (AT) service was being provided?* Pre-referral or referral for AT service Assessment of AT needs AT consideration and planning Documentation of AT in IEPs AT experimental trial Locating AT information Fabrication of AT devices AT equipment setup Training how to use AT devices Implementing AT services AT consultation and collaboration AT troubleshooting Working with the AT consumer's family AT follow-up and evaluation Administration and supervision Other If Other, describe: Comments Provide any other information that you may believe is relevant: CONTACT Optional information: If you would like to be contacted to provide more information about effective or ineffective assistive technology experiences, please provide your name and email address, or phone, in the box below. PLEASE REMEMBER, THIS IS OPTIONAL. Click to record the information you entered. Click to clear your entries and start over If you have questions or comments about this research, send an e-mail message to the Critical Incident Investigation Manager, Elizabeth A. Lahm, at ealahm1@uky.edu This research is being conducted by the National Assistive Technology Research Institute, which is supported by the University of Kentucky and by Cooperative Agreement #H327G000004 from the Research to Practice Division, Office of Special Education Programs, U. S. Department of Education. Results of the research do not necessarily reflect the views or official positions of the supporting agencies. • Return to Top • Return to Critical Incident Study An Equal Opportunity University Last Updated: Wednesday, April 19, 2006 © 2001-2006 - National Assistive Technology Research Institute - All rights reserved NATRI documents may be reproduced for non-commercial purposes provided their source is identified.