Templates & Samples

Evaluation Example Letters

Following are some examples of AAC evaluation reports for a variety of language systems and diagnoses. Please feel free to use these as a starting point and customize for your client.

Speech Evaluation Worksheet for SLPs

This data collection worksheet is designed for evaluating therapists to make notes as they complete an AAC evaluation and is directly applicable to the complete AAC Evaluation found online. Please note: This is not an exhaustive document; rather, it provides the overall structure of the online report writing tool.

   Download the worksheet

PRC

  AAC Evaluation for an SGD Example (PDF) 
  AAC Evaluation for an SGD - Autism Example (PDF) 
  AAC Evaluation for an SGD - Rett Syndrome Example (PDF) 
  AAC Evaluation for an SGD - Cerebral Palsy Example (PDF) 
  AAC Evaluation for an SGD - CVA Example (PDF) 
  AAC Evaluation for an SGD - Down Syndrome Example (PDF) 
  AAC Evaluation for an SGD - Essence Example (PDF) 
  Repair Evaluation Example (PDF) 
  Trial Evaluation (PDF) 
  Trial Evaluation Spanish (PDF) 

Saltillo

  AAC Evaluation for an SGD – Autism Example (Saltillo PDF)
  AAC Evaluation for an SGD – Cerebral Palsy Example (Saltillo PDF)
  AAC Evaluation for an SGD – CVA Example (Saltillo PDF)
  AAC Evaluation for an SGD – Down Syndrome Example (Saltillo PDF)
  Repair Evaluation Example (Saltillo PDF)

Addendum Templates

   Addendum to AAC Evaluation Requesting Purchase
   Addendum - New Access Method
   Deferral Addendum
   NuEye to Look Addendum
   Outdated Evaluation Addendum
   Trial Summary – Single Site

Appeal Example Letters

Despite the best of efforts, not every funding request results in a positive outcome. Many times, however, decisions can be overturned by following the appeal process outlined by the funding source.

Following are some examples of appeal letters with common reasons for denial. Please feel free to use them as a starting point when going through the appeals process.

  12-Week Rental Not Approved (PDF)
  Can Be Used for Purposes Other Than Communication (PDF)
  Client Already Has Device (PDF)
  Client Does Not Need High-tech Device (PDF)
  Client is Not Able to Use This Device Independently (PDF)
  Comfort or Convenience (PDF)
  Medical Necessity of LAMP Words for Life® (PDF)
  Preferred Provider Arrangement with Another Vendor (PDF)
  iPad Good Enough (PDF)

For information on your rights under various programs, aid from protection and advocacy organizations, and appeal support, visit the U.S. Department of Labor's Disability Resources website.

Other Resources

SGD Funding Solutions from Assistive Technology Law Center
The National Assistive Technology Advocacy Project

  Trial Data Collection Sheet (PDF)
  Deferral-Denial Quick Reference Guide (PDF)
  Medical Release Form