Appendix A-1: DeSSA Accessibility Form Cover Page



Appendix A-1: DeSSA Accessibility Supports FormFor SAT student accommodations – Use Appendix D-1General Student Information: Completion Date:Student Name:Date of Birth:Student ID:District:School:Grade:Implementation Date:Assessment(s)/Content Area(s)Select the appropriate category: Student has an IEP/504 plan (Levels 1, 2, & 3) Student is an English Learner (Levels 1 & 2) Student has an IEP/504 plan AND is English Language Learner (Levels 1, 2 & 3) Student is a General Education Student with identified needs (Levels 1 and 2)*** Print-on-Request – For a student who does not have IEP/504, Submit a Unique Accommodation Request Not available as a checkbox in TIDE Bold – DE accomm; DOE approval not required Orange – DOE approval required Embedded: Provided by the Test Delivery System Non-Embedded: Provided outside the Test Delivery System Level 1: UniversalA-2 DESC.ELAELA-PTMATHSCISOC STLevel 1: UniversalA-2 DESC.ELAELA-PTMATHSCISOC STEmbeddedNon-EmbeddedAnswer Eliminator1---YYBreaks (Frequent Breaks)3?????Answer Masking1---YYEnglish Dictionary3-?---Breaks 1YYY--Familiar Test Administrator3?????Calculator 1--Y--Modified Lighting3???--Digital Notepad1YYYYYRefocus3?????English Dictionary1-Y---Scratch/Blank/Grid Paper3?????English Glossary1YYY--Small Group3?????Expandable Passages and/or items1YY---Specialized Equip/ Furniture3?????Five Function Calculator (Gr.8, HS)1---Y-Specified Area/Preferential Seating3?????Global Notes2-Y---Thesaurus4-?---Highlighter2YYYYYTime of Day4???--Keyboard Navigation2YYYYY Whiteboard/Assistive Devices4?????Line Reader2YYYYYLevel 2: Designated SupportsMagnifier2---YYEmbeddedMark for Review2YYYYYColor ContrastContrast Choice: ______________________________4YYY--Math Tools2--Y-- ???--Notepad2---YYEnhanced Mouse Pointer4---??Spell Check2YYYYYEnhanced ZoomSelect Size 100 110 120 150 175 200 4---??Strikethrough2YYY--Text-to-Speech 2---YYMasking4???--Thesaurus2YYY--Mouse Pointer4???--Writing Tools2YYYYYPermissive Mode4???--Zoom3YYYYYSpanish4---??Level 2: Designated SupportsA-2 DESC.ELAELA-PTMATHSCISOC STLevel 3: AccommodationsA-2 DESC.ELAELA-PTMATHSCISOC STEmbeddedEmbeddedStreamline 4???--American Sign Language Video8?????Text to Speech Items5?----Braille Contracted 8??Passage/Stimuli Items-??--Uncontracted??-Translation of Key Terms5---??Nemeth--?--Translated Test Directions 5--?--Braille Transcript (ELA List Passages)8??---Translations (Glossary) Language: ______________________5YYY--Closed Captioning8??-----?--Emboss Request Type On-Request8???--Translations (Dual Language)5--?-- Auto-Request???--Turn off any Universal Tools???--N/A- not using refreshable Braille???--Non-Embedded Emboss Request Type On-Request8???--Amplification/Assist. Listening Device5????? Auto-Request???--Bilingual Dictionary6-?-??N/A- not using refreshable Braille???--Color Contrast (printed)6???--Speech-to-Text8Color Overlays6?????Text-to-Speech w/ Graphics8---??EL First Year Exemption6??---Text-to-Speech ELA Passages 8?----Human Interpreter Native Lang6--???Non-EmbeddedHuman Read Aloud Items only6?----100s Number Table8--?--Passage/Stimuli/Items -????Abacus8--?--Spanish--?--Alternate Response8???YYMagnification (via external device)6???--Braille (P/P)9?????Medical Supports 7?????Calculator (handheld adaptive)9--?--Noise buffers7???--Human Interpreter – Visual Comm 9?????Paper/Pencil test 7???--Human Read Aloud – passages 9?----Scribe7?-???Large Print 9?????Separate Setting in school7?????Math Manipulatives 9--?--Separate Setting Not in School 7?????Multiplication Table 9--?--Simplify directions 7???--Paper/Pencil9---??Translated Test Directions - Print7???--***Print on Demand Items 10???--Translations –Glossary – P/P7--?--Passage/Stimuli???--Unique Accommodation 7?????Scribe for SWD/ SWD/EL10-?---Scribe-InjuryYYYYYWord Prediction10??---List below any accessibility features selected for which the student needs additional practice or preparation. (add rows as needed)Describe what practice or preparation is needed:Accommodation/ContentWhat Practice/Preparation is needed? ................
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