Please complete this form. The information you provide will help determine how to mee the client’s workplace accommodation and computer training needs. This assessment should be completed 2-3 weeks prior to job start date.

SECTION 1 — CLIENT INFORMATION

• Client Name:

• Job Title:

• Employer Name:

• Employer Address:

• Work Phone:

• Describe Job Responsibilities:

• Work Hours:

• Supervisor’s Name:

• Supervisor’s Phone:

• Supervisor’s E-Mail:

• Technical Support Person:

• Tech’s Phone:

• Tech’s E-Mail:

SECTION 2 — EMPLOYER’S SOFTWARE INFORMATION

• Operating System used on PC’s:

• Applications Used:

• E-Mail

• Internet: No internet for the client

• Proprietary Software:

• Other (Please Specify):

• Network Environment:

  • If networked, will the client need access to more than one PC (i.e., will the client ever switch to another workstation)?

SECTION 3 — COMMON TASKS

• List common tasks the client will perform (i.e., answer phones, word processing, etc.):

SECTION 4 — ASSISTIVE TECHNOLOGY

• List any assistive technology the client currently has:

SECTION 5 — OTHER INFORMATION & COMMENTS

Counselor:

Date: