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1 Name: Date: [ ] Initial Assessment [ ] Re-evaluation [ ] Special Request by IFSP Committee FUNCTIONAL VISION/ LEARNING MEDIA ASSESSMENT WORKSHEET Birth – 3 YEARS Student Name: Date of Birth: Evaluator”s Name: Evaluator”s Name: Evaluator”s Name: 1st: Date(s) of Test: 2nd: Date(s) of Test: 3rd Date(s) of Test: RECORDS REVIEW MEDICAL HISTORY: LAST EYE EXAM Name of eye doctor: (circle one) ophthalmologist Exam Date: Visual Acuity Without Glasses: With Glasses: OD optometrist low vision specialist OS Near: Near: OD other: ______________________ OS Distance: Distance: If acuity cannot be measured, student is [ ] Legally Blind [ ] Not Legally Blind Muscle Function: Visual Fields: Intraocular Pressure Readings: Color Vision [ ] Normal Diagnosis: Prognosis: Etiology: Treatment Recommended: Precautions or Suggestions: [ ] Abnormal Photophobia: [ ] Yes [ ] No 2 Name: Date: [ ] Patient appears to have no vision [ ] Patient has a serious visual loss after correction. [ ] Patient does not have a serious visual loss after correction Glasses: ___ yes ___ no used for: _______________________ Low Vision Aid: ___ prescriptive ___ non prescriptive used for: ________________________ Has learner received training in use of aid? ___ yes ___ no If yes, where and for how long was training received: ______________________________ Doctor’s recommended restrictions on physical activity (if any): ADDITIONAL ASSESSMENTS Motor Ability ___ Within Normal Limits ___ Other: ___ Needs to be addressed Name of Assessment: Date(s) of Assessment: Assessor’s Name: Auditory Ability ___ Within Normal Limits ___ Other: ___ Needs to be addressed Name of Assessment: Date(s) of Assessment: Assessor’s Name: Cognitive Ability ___ Within Normal Limits ___ Other: ___ Needs to be addressed Name of Assessment: Date(s) of Assessment: Assessor’s Name: Other Assessments to be Considered: Additional Information to be Considered: Medication Type and dosage: __________________________________ Time of day administered: ___________________________ 3 Name: Date: PARENT INTERVIEW Please keep in mind this is only a sampling of questions. 1. Can your child see? 2. What behaviors tell you so? 3. What things does your child look at most consistently? 4. What does your child like to do 5. What doesn’t your child like to do 6. Tell me about your day with you and your child 7. When is your child most alert? 8. How does your child communicate with you? 9. What does your child like to eat? 10. Are there smells your childs enjoys more than others? 11. What sounds does your child like? 12. What sounds does your child not like? 13. Will your child touch new textures? 14. What textures does your child not like? 15. What would you like to see your child do? 16. What are your hopes for your child’s future? 17. What else would you like me to know about your child 4 Name: Date: ASSESSMENT AREA I: PHYSICAL-OPTICAL Student receives medication at: (time of day) Evaluation began at : __________ (time of day) . Student’s level of awareness was:(check one only) ___ Asleep-Inactive ___ Drowsy ___ Awake Inactive-Alert ___ Awake-Active/Self stimulatory ___ Seizuring ___ Asleep-Active ___ Daze ___ Awake Active-Alert ___ Crying/Agitated A positioning evaluation has been done by: (circle) OT PT (date): Recommendations which were utilized during this evaluation were: Student was wearing glasses during current evaluation? Yes No N/A Describe how the eye looks: (i.e. redness, irregular shaped pupils, etc) The following were present: Pupil reaction to light: Not Tested OD: YES NO OS: YES NO How was it tested: ___________________________ Photophobia: Not Tested YES Eye preference: Not Tested YES NO if yes: OD OS How was it tested: ___________________________ Blink reflex: Not Tested YES Nystagmus: YES OD OU Muscle imbalance: NO OS Not Tested NO NO YES NO How was it tested: ___________________________ Eccentric viewing: YES NO If YES describe how head was tilted: _____________________________ Unusual Visual Behaviors YES NO specify: _____________________ 5 Name: Date: A response of NO would indicate an area of concern and would need further comments. Makes an attempt to use vision. YES NO Attempts to use vision for most purposes. YES NO Uses both central and peripheral vision. If NO: Uses central vision only. Uses peripheral vision only. YES NO YES YES NO NO Student is aware of ability to see things. YES NO Student attends and looks consistently. YES NO Student shows curiosity about visual objets. YES NO Behavioral Characteristics Related to Cortical Visual Impairment: Expressionless face YES NO Eye movements smooth but aimless YES NO Visually inattentive YES NO Tends to look away from people and events YES NO Peripheral vision appears to be more functional YES NO Attends best to movement and to toys in motion YES NO Sees better in familiar environment YES NO Lacks visual curiosity YES NO Spontaneously uses vision only for short periods of time YES NO On reaching, turns head and may exhibit downward gaze YES NO 6 Name: Date: COMMENTS Appears unable to recognize stationary objects YES NO Focuses on only one toy among several YES NO May not recognize faces YES NO Depth perception poor, reach is inaccurate YES NO Rarely bumps into objects during travel YES NO Balance seems better when eyes are closed YES NO When moving, appears to see stationary objects YES NO Usually holds head up except when reaching for visual stimuli YES NO ACUITIES Distance: OD _____ OS _____ OU _____ Near: OD _____ OS _____ OU _____ Test(s) Used: ______________________________________ If acuity cannot be assessed Describe what child visually is aware of at: (note size of object, patterns if applicable, sound if any) 0-6 inches: 6-12 inches: 1-3 feet: 3-5 feet: 5-8 feet: 10 feet: Beyond 10 feet: 7 Name: Date: Peripheral Vision: Use penlights/objects brought from behind the student toward the outer edge of vision and from the waist up to the bottom edge of expected vision, and from approximately two (2) feet above the head to the edge of vision. ___ Not tested at this time How Tested: OD ___ upper ___ upper oblique right ___ upper oblique left ___ left ___ lower ___ lower oblique right ___ lower oblique left ___ right OS ___ ___ ___ ___ ___ ___ ___ ___ upper upper oblique right upper oblique left left lower lower oblique right lower oblique left right _____ No Response to Peripheral Vision Peripheral vision [was, was not] found to have a discrepancy. If yes, the discrepancies were found to be located in the following areas: OD: OS: ___ Upper ___ Upper ___ Lower ___ Lower ___ Left ___ Left Attitudes Toward Tasks During Present Assessment ___ Cooperative ___ Uncooperative ___ Attentive ___ Restless ___ Enthusiastic ___ Reluctant ___ Relaxed ___ Tense ADDITIONAL COMMENTS: ___ Right ___ Right OU ___ ___ ___ ___ ___ ___ ___ ___ upper upper oblique right upper oblique left left lower lower oblique right lower oblique left right 8 Name: Date: ASSESSMENT AREA II: Visual and Auditory Motor Development + skill observed - skill not observed * see comments n/a not tested VISUAL MOTOR COMMENTS: ___Demonstrates head control. ___Demonstrates trunk control. ___Does the student exhibit visual behaviors (i.e. light gazing, flicking, etc.) explain: ___________________ ___Reacts to a light. Specify: natural ___ artificial ___ colors: ___________________ distance: ___Turns eyes to light ___ and/or colors ____ color preferred: _____________ distance: fluorescent ___ incandescent ___ type of light: ___Localizes to a large target by contour/pattern. specify target and distance: Sense primarily responded with: VISUAL TACTUAL AUDITORY ___Notices color differences Color(s) preferred: ______________ Size of target: __________ Distance: __________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___Localizes toward vocalizing face. specify distance Sense primarily responded with: VISUAL TACTUAL AUDITORY ___Localizes toward non-vocalizing faces. specify distance: Sense primarily responded with: VISUAL TACTUAL AUDITORY TACTUAL AUDITORY ___Uses consistent binocular fixation ___Will inspect own face in mirror ___Fixates eyes on stationary object for _____ seconds. Specify object: size: color: distance: Sense primarily responded with: VISUAL ___Fixates on distant object for _____ seconds. COMMENTS 9 Name: Date: Specify object: size: color: distance: Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks object horizontally to midline. ___ right to midline ___ left to midline Specify object: size: color: distance: Tracks with: [1] eyes only [2] head & eyes [3] whole body Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks object in a vertical direction. ___ upward direction ___ downward direction Specify object: size ________ color _________ distance _____ Tracks with: [1] eyes only [2] head & eyes [3] whole body Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks across midline 180 degrees. Specify object ____________________ size ______ color ___________ distance _____ Tracks with: [1] eyes only [2] head & eyes [3] whole body Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks object in a diagonal direction ___ upward ___ downward Specify object _______________ directionality: left: downward-to-upward upward-to-downward right: downward-to-upward upward-to-downward size ______ color ___________ distance _____ Tracks with: [1] eyes only [2] head & eyes [3] whole body Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks object in a circular direction ___ clockwise ___ counterclockwise Specify object ____________________ size ______ color ___________ distance _____ Tracks with: [1] eyes only [2] head & eyes [3] whole body Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Moves eyes in unison to track object. Specify object ____________________ size ______ color ___________ distance _____ ___ Moves eyes toward object in own hand. Specify object: color: Produces sound? ___ yes ___ no Sense primarily responded with: VISUAL TACTUAL AUDITORY COMMENTS 10 Name: Date: ___ Visually tracks falling object. Specify object ____________________ size ______ color ___________ distance _____ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Looks from one object to another. [shift gaze] ___ horizontally ___ vertically ___ diagonally Specify objects ________________________________ size/s____________ color/s ______________ distance ______________ Produce sound? ___ yes ___ no Who is holding objects? _________________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Will alternate eye gaze from object in hand to surroundings or another object. Specify objects ________________________________ size/s____________ color/s ______________ distance ______________ Produce sound? ___ yes ___ no Who is holding objects? _________________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Will alternate eye gaze from one object in near space (3-12") to far space (6-20') Specify objects ________________________________ size/s____________ color/s ______________ distances used: ______________ Produce sound? ___ yes ___ no Sense primarily responded with: VISUAL TACTUAL AUDITORY Who is holding objects? _________________________________ ___ Eyes continue to converge as object and/or light is moved within _________ inches of face. Specify object _____________ size ______________ color ______________________ ___ Eyes continue to diverge as object and/or light is moved away _________ inches of face. Specify object _____________ size ______________ color ______________________ ___ Demonstrates ability to recognize common objects size ___________ color _____________ distance _________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Demonstrates ability to recognize familiar people. Specify people _______________ distance ____________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY TACTUAL AUDITORY ___ Will give eye contact with people specify distance: ___ Visually and/or tactually explores owns hands. Sense primarily responded with: VISUAL ___ Grasps object for five to ten seconds. Specify object ___________________________ color ____________________ size ______________ texture ___________________ COMMENTS ___ Hand/s approached midline. Specify: left ____ right ____ together ____ 11 Name: Date: ___ Demonstrates meaningful movement by reaching for a single object when placed within reach. Specify object _________________ size ______ color __________ distance __________ texture ______________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Rakes to secure object. Specify object ______________________ size _____________ color ______________ texture ___________________ sound producing: ___ yes ___ no Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Reaches for, and grasps object. ___ palmer grasp ___ pincer grasp Specify object _______________ size ________________ color ______________ texture ____________________ sound producing: ___ yes ___ no Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Accurately reaches for objects or people YES NO if NO specify: ___________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Rotates wrist when object is in hand. Specify hand _______ object _____________ size __________ color _________________ ___ Brings both hands to midline. Specify activity _____________________________________ ___ Transfers object from one hand to another. Specify object _________________________ size ________ color _____________ texture _______________ sequence of transfer: __________________________________ ___ Will orient torso toward object ___ left ___ right ___ behind Sense primarily responded with: VISUAL ___ Student’s position during items 1-48 was: TACTUAL AUDITORY 12 Name: Date: AUDITORY MOTOR COMMENTS ___ Startle reflex in response to sound. Identify sound level and type of sound: _____________ ___ Show awareness of sound. specify: _______________________ how shown: ________________________ ___ Responds differently to familiar sounds. specify: _______________________ how shown: ________________________ ___ Pays particular attention to tones of voices (smiles at soft voices, cries at angry voices) specify: _______________________ how shown: ________________________ ___ Attends to musical and rhythmical sounds. specify: ________________________ how shown: ________________________ ___ Demonstrates a sound preference. Specify ________________________ how shown: ______________________ ___ Demonstrates sound localization by turning to sound. ___ right ___ left ___ in front ___ behind Specify sound ___________________ how shown: ______________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks moving sound source horizontally. specify: _______________________ how shown: ________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tracks moving sound source vertically. specify: _______________________ how shown: ________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Reaches for sound producing object. Specify object ____________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Discriminates a nearer sound from a sound that is farther away specify: _______________________ how shown: ________________________ ___ Discriminates between two types of sounds (i.e. bell, drum, squeaky toy, etc.) specify: _______________________ how shown: ________________________ ___ Discriminates sound by pitch specify: _______________________ how shown: ________________________ ___ matches sound ___ identifies sound ___ Discriminates sound by duration specify: _______________________ how shown: ________________________ ___ matches sound ___ identifies sound ___ Discriminates sound by rhythm specify: _______________________ how shown: ________________________ ___ matches sound ___ identifies sound COMMENTS Name: Date: ___ Can match sequence of sounds (i.e. teacher rings bell, then student rings bell) ___ one sound ___ two sounds ___ three sounds specify: _______________________ how shown: ________________________ ___ Carries out verbal commands. ___ one command ___ two commands ___ three commands specify: _______________________ how shown: ________________________ ___ Will attend to intended sound source with distracting sound source(s) present. specify: _______________________ how shown: ________________________ ___ Will follow a simple command when distracting sound source(s) are present. specify: _______________________ how shown: ________________________ ___ Student's position during items #50-69 was: _______________________________________ COMMENTS: 13 14 Name: Date: ASSESSMENT AREA IIIA Indoor Visual Environment/Academic Environment + skill observed - skill not observed * see comments n/a not tested COMMENTS ___ Pulls peg from pegboard. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Searches interior of box Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Selects a favorite toy from a group of three. Specify choices given ____________________ selection made ____________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Tries to locate object that has fallen out of sight and/or reach, demonstrating object permanence. Specify object _______________________ size ________________ color ___________ distance from student _________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Places small object in container. Specify object ________________ size ______________ container size ________________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Places object/s in small-mouthed container. Specify object ____________________ size __________________ container size __________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Places objects accurately (i.e. circle in formboard, shapes in shapesorter)? Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Hold objects in correct position after looking at how they should be positioned? specify objects: __________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Dumps object/s from small-mouthed container. Specify object _________________ size __________________ container size __________________________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Is interested in books. Sense primarily responded with: VISUAL TACTUAL AUDITORY COMMENTS ___ Builds a tower using cubes/blocks. 15 Name: Date: ___ size of blocks ___ number of blocks Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Scribbles. Describe how ___________________________________________________ Sense primarily responded with: VISUAL TACTUAL ___ Is able to match colors: specify: ___ Is able to match textures specify: Sense primarily responded with: VISUAL TACTUAL ___ Understands concepts of big and little. ___ matches ___ identifies Sense primarily responded with: VISUAL TACTUAL ___ Understands concepts of soft and hard. ___ matches ___ identifies Sense primarily responded with: VISUAL TACTUAL ___ Understands concepts of tall and short. ___ matches ___ identifies Sense primarily responded with: VISUAL TACTUAL ___ Understands concepts of in and out. ___ matches ___ identifies Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Understands concepts of open and closed. ___ matches ___ identifies Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Understands concepts of same and different ___ matches ___ identifies Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Imitate gross motor movement note distance: ___ yes ___ Shapes ___ matches ___ identifies Sense primarily responded with: ___ no VISUAL TACTUAL COMMENTS ___ Plays with toys Sense primarily responded with: VISUAL TACTUAL AUDITORY 16 Name: Date: ___ Visually inspects immediate surroundings note distance: specify objects: size: ___ Attends to TV or films ___ visually ___ auditory ___ Attends to and responds meaningfully when others read Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Differentiates objects Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Identifies objects Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Student’s position during evaluation Assessment Area III was: 17 Name: Date: ASSESSMENT AREA IIIB Indoor Visual Environment/Non-Academic Environment + skill observed - skill not observed * see comments n/a not tested COMMENTS ___ Recovers balance when placed off balance in sitting position ___ Recovers balance when placed off balance in standing position. ___ Moves around in or explores environment. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Reaches out to explore immediate environment. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Reaches out to contact wall/door with hand/foot. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Travels by following along wall (may have both hands in contact with wall, may travel by side stepping. ___ Reaches for objects within arm's length. object: ____________ sound producing: ______________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Moves toward objects within 5 feet object: ____________ sound producing: _____________ distance: ___________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Moves toward objects over 5 feet away object: ____________ sound producing: ____________ distance: ____________ ___ Detects moving objects: object: ____________ sound producing: _____________ distance: ____________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Detect stationary objects: object: ____________ sound producing: _____________ distance: ____________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Locates objects in a room (i.e. table, toilet). Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Moves around obstacles and maintains line of travel. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Uses textured cues in room (i.e. material, smell ,etc.) to determine location in room. COMMENTS ___ Has developed "motor memory" (slows down just before reaching stairs, reaches for door knob as door is felt, etc.) 18 Name: Date: ___ Reaches out to explore an unfamiliar area. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Reaches out and searches for a wall in an unfamiliar area. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Walks with an age appropriate gait. ___ Locates chair and seats self. ___ independently ___ with assistance ___ Pulls chair up to table ___ Is aware of dropped/lost objects. Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Uses random gestures in searching for dropped/lost object within arm's reach Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Locates dropped/lost objects when stationary Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Locates dropped/lost objects when moving Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Student can imitate pose and/or gesture: note distance: __________ Sense primarily responded with: VISUAL TACTUAL AUDITORY ___ Moves toward sound source LIGHTING Student can locate source of natural light YES NO Student can locate source of artificial light YES NO Student’s visual usage is increased YES NO with use of light Describe activity and lighting conditions: _______________________________________________________________________ Student prefers to control indoor lighting by: ___ wearing tinted glasses ___ wearing visor/hat/cap ___ turning from source of light ___ adjusting window shades ___ creating shaded area ___ other: __________________ Extended Core Curriculum 19 Name: Date: The following skill checklists are just a representation of various checklists. A complete assessment of these skills can be done using the "Independent Living--ACurriculum with Adaptations for Students with visual Impairments" developed by TSBVI or other curriculums. SELF HELP SKILLS (check all that apply) __ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ Is bottle fed. holds own bottle Accepts and chews bite sized pieces of solid food. Feeds self with fingers Drinks from a cup or glass Chews foods Accepts a varied diet. Differentiates edible foods from non-edible items. Drinks from a straw. Unwraps packaged foods Uses a spoon to scoop food and bring food to mouth. Eats with a fork. Eats a sandwich dries hands and face turns faucet on and off washes hand and face helps in the bathing process Blows and wipes own nose ___ Cooperates for undressing ___ Independently removes: socks, pants, underpants shirt, shoes, hat, and coat (undone) ___ Assists in dressing (arms through openings, etc.) ___ Independently puts on pants and shirt. ___ Independently puts on socks and hat. ___ Independently puts on shoes ___ Independently unzips, unsnaps, unlaces, and unhooks ___ Uses zip, snap, velcro and hook fasteners ___ Unbuttons ___ Buttons large buttons ___ Identifies articles of clothing List: _________________________ ___ indicates when diaper/pants are wet ___ Indicates nee to use the toilet ___ Uses toilet with assistance ___ Uses toilet paper ___ Toilets with no accidents Areas of Strengths: Areas of Concern: DAILY LIVING SKILLS (check all that apply) ___ Plays in/with various textures (sand, water, balls, etc.) ___ Stirs ingredients ___ Pours solid foods ___ Participates in preparing foods ___ Pours liquids ___ Uses a toaster ___ Anticipates next activity in a daily routine ___ Demonstrates an understanding of future events. Areas of Strengths: Areas of Concern: SELF ADVOCACY (check all that apply) ___ Pretend play familiar actions with/without props ___ Hangs clothing on hooks or over bars ___ Identifies and matches shoes ___ Drops trash in trash basket ___ Picks up and places toys on shelf ___ Stacks dishes ___ Demonstrates an understanding of past events ___ Will wait for several minutes to get needs met Name: Date: ___ Indicates where pain is ___ Informs others when he can do something independently ___ Answers simple yes/no questions 20 ___ Tolerates wearing glasses and/or other simple adapted devices. Areas of Strengths: Areas of Concern: SOCIAL SKILLS (check all that apply) ___ Responds to adult's interaction ___ Differentiates between familiar people and strangers ___ Demonstrates understanding of approval and disapproval of adults ___ responds to name being called ___ Attends to task until completed ___ Cooperates in play with another child(ren) ___ Will share toy with a peer ___ Takes turns ___ Shows pride in accomplishing tasks ___ Demonstrates concern for another person ___ Initiates and responds to farewells and greetings ___ Willing to try new things Areas of Strengths: Areas of Concern: COMMENTS: ___ Initiate interactions with an adult ___ Accepts a substitute activity that replaces a socially unacceptable mannerisms ___ Addresses family members by name ___ faces person talking ___ Seeks adult interaction for play (child initiated) ___ Will occupy time with play with objects not used for self-stimulatory behavior ___ States own name ___ Uses pronouns, I, you, and me. ___ Demonstrates affection for family members ___ Makes choices about objects or activities by accepting or refusing them 21 Name: Date: ASSESSMENT AREA IV OUTDOORS VISUAL FUNCTIONING + behavior observed - behavior not observed * see comments n/a not tested COMMENTS ___ Student is sensitive to natural sunlight ___Student squints or shield eyes from the sun Student prefers to control outdoor lighting by: ___ wearing tinted glasses ___ wearing visor/hat/cap ___ turning from source of light ___ seeking shaded areas ___ creating shaded area ___ other: __________________ ___Is there an adjustment period needed when going from inside light to outside light? Describe: ___ Student is able to scan to locate objects Describe objects: Distance noted: ___Student is able to distinguish between sidewalk/patio and grass ___ Student is able to detect surface changes in a familiar area. ___ Student is able to detect surface changes in an unfamiliar area ___ Maintains balance when negotiating varied surface changes. ___ Student is able to negotiate play area ___ Student is able to see variations in play area ___ Student uses visual landmarks to establish line of direction ___ Students is able to see stationary cars. Distance noted: ___ Student is able to see moving cars. Distance noted: Student’s vision is affected by: COMMENTS: ___ clouds ___ rain ___ fog/haze ___ shade/dark areas ___ heat ___ cold ___ snow 22 Name: Date: ASSESSMENT AREA V TECHNOLOGY/ASSISTIVE TECHNOLOGY List current modifications student is using to access information: (i.e. bold line drawings; materials with high contrast, tactual materials, switches, etc.) List current devices student is using to access environment (i.e. pre-cane device, cane, wheelchair, special seating equipment, switches, etc.) Is the student able to access a computer? How does student access information on computer Visually: Size of print/pictures: Color contrast of monitor: Size of pointer: Auditory: Use of ear phones: Use of auditory output: Switches: Type of switch(s): Position of switch(s): Mouse use: Types of mouse: Position of mouse: Keyboard use: Type of keyboard: Position of keyboard: COMMENTS: 23 Name: Date: LEARNING MEDIA ASSESSMENT Sensory Channels Based on the Functional Vision Evaluation, student behaviors, parent/teacher interview and the eye doctor's report: Primary sensory channel: visual auditory tactual ongoing assessment needed Secondary sensory channel: visual auditory tactual ongoing assessment needed Examples of this are: Visual Strengths: Visual Weaknesses: Auditory Strengths: : Auditory Weaknesses: Tactual Strengths: Tactual Weaknesses: General Learning Media: Visual (note distance if applicable) __ high contrast __ bright colors __ lightbox __ pictures __ print __ magnifiers __ other: Literacy Media: Primary: Secondary: Auditory Tactual __ taped material __ verbal instructions __ manipulative objects __ hand over/under hand modeling __ raised line pictures __ tactual sign __ other: __other: Name: Date: Based upon the Learning Media Assessment, this student’s Literacy Program will include __ Convention Literacy Program (at a prereading or readiness program) __ tactual __ regular print __ large print __ ongoing assessment needed __ Functional Literacy Program (for students with additional disabilities) __ tactual __ regular print __ large print __ ongoing assessment needed __ Other Literacy Program (for studens who are functioning at a level such that a conventional or functional literacy program is not appropriate now) Please describe: __ tactual __ regular print __ large print __ ongoing assessment needed COMMENTS: 24 25 Name: Date: YES NO Functional visual evaluation addresses the use of both near and distance vision in a variety of environments. Based on data from the Functional Vision/Learning Media evaluation this student is: YES NO Student is functionally blind. Definition: A student who is visually impaired is functionally blind if, based on the Functional Vision/Learning Media evaluation, the student will use tactual media (which includes braille) as a primary tool for learning to be able to communicate on both reading and writing at the same level of proficiency as other students of comparable ability. YES NO Student is functionally blind but additional ongoing assessment is necessary to determine if braille or print should be the primary literacy media. YES NO Student is a tactual learner but is functioning at a cognitive level such that instruction in pre-braille, braille readiness, or braille reading and writing in not appropriate at this time. YES NO Student is not functionally blind but has reduced vision that interferes with educational progress YES NO Student is functioning at a cognitive level such that instruction in reading or writing is not appropriate at this time. YES NO Student's visual loss does not interfere with educational success ELIGIBILITY STATEMENT ___YES This student meets eligibility criteria to receive services from the teacher of visually handicapped students as defined by the State Board of Education Rules #89.211(d). ___ NO This student does not meet eligibility criteria as defined by the State Board of Education Rules #89.211(d). ** This child should be referred for a low vision evaluation YES NO WHY: 26 Name: Date: **The child should be referred for an orientation and mobility evaluation YES NO WHY: Other Evaluations Needed: ___ Adaptive Physical Education ___ Assistive, Adaptive Devices ___ Auditory ___ Occupational therapy ___ Physical Therapy ___ Speech & Language ___ Other: IMPLICATIONS FOR THE EDUCATIONAL PROCESS RECOMMENDATIONS ___ Current eye report is out or date or does not accurately portray what student is currently seeing ___ obtain a new/updated report ___ visual fields need to be assessed ___ Best functional vision was observed to exist: OD: ___ inches, ___ field(s) OS: ___ inches, ___ field(s) OU: ___ inches, ___ field(s) Distance tasks should be: ___ feet from student ___ inches in size Near tasks should be: ___ inches from student ___ inches in size Other: ___ Student has diagnosed reduced, or spotted visual fields ___ May have difficulty seeing detail ___ May have difficulty seeing steps, protrusions, or other visual cues ___ Limit size of material being presented ___ Make sure student is given time to view all of material ___ Encourage exploration of whole room or materials to accommodate viewing needs ___ There is a possibility of visual field loss due Observe visual responses in various 27 Name: Date: to brain injury or birth trauma visual fields. Consistent responses noted in visual field: distance: size of object: color of object: other: ___ Student’s primary visual use is peripherally located Present materials Visual field: Size of object: Allow student to maintain a natural body Position to prevent physical fatigue. Other: ___ Student demonstrated color deficiencies Colors student cannot distinguish: Tasks involving color recognition are inappropriate for this student Other: ___ Student is highly distractable ___ need an auditorially sterile environment during teaching times ___ needs a visually sterile environment during teaching times ___ Teacher should not wear distracting items ___ Present material from behind student ___ Present material in small single steps ___ Other: ___ Student’s posture effect visual functioning ___ needs to be in a comfortable, supported, upright & sitting position (i.e. food presentation at child’s eye level) ___ in supine position, need head support of at least ___ inches to reduce neck & shoulder tightness & allow full ocular motility (check with PT) ___ in prone place a mirror at such an angle to allow student visual access of the area behind and to the sides ___ postures recommended by PT/OT for best support and visual usage are: ___ Other: 28 Name: Date: ___ visual use is affected by the tightness in neck & shoulder area ___ use of a slanted work space for viewing ___ position(s) recommended by OT/PT in presenting materials: ___ student need preparation for touch or movement to decrease behavios of irritability, fear, visual and/or tactual avoidance ___ needs short, concise signals (auditory, visual or tactual) before being picked up ___ hand-over-hand modeling ___ hand-under-hand modeling ___ object cueing ___ other: ___ Limited movement retards visual usage ___ Because movement stimulated the receptors of the brain, it also stimulate the visual center and readies it for receiving information. To facilitate this visual stimulation: ___ place child in a variety of positions ___ place child in a variety of environments ___ place child on a variety of textures ___ implement a proprioceptive movement program as recommended by PT/OT ___ use of active learning environments: describe: ___ Other: ___ Medication being ingested has a number of possible ocular side effects List types of side effects: Times to avoid important skill lessons due to side effects: ___ Student’s eye condition can result in fluctuation of visual efficiency Best time of day for visual use: Best visual field to present information: Times to avoid visual tasks: Areas to avoid visual tasks: Needs a sterile environment for best visual use: Describe: ___ visual fluctuations may signal changes in ocular or optic pressures. Contact parent/eye doctor immediately 29 Name: Date: ___ Abrupt changes in lighting can cause discomfort which results in temporary decreased vision ___ allow time for child’s vision to adjust to lighting changes. Time needed: ___ use of a cap or sun visor to reduce overhead glare ___ use of colored lenses or sunfilters Describe: ___ use of a non-reflective work surface ___ use of non-reflective materials ___type of lighting preferred: ___ position of lighting preferred: ___ prefers to work in dim light ___ Other: ___ Student does not exhibit the ability to focus and track ___ pair visual stimuli with auditory and tactile timuli to provide meaning to instructional activities ___ Other: ___ Student exhibits lack of motor control ___ allow an extended response time ___ use of weights to help understand body in space ___ PT/OT recommendations for additional adaptive equipment ___ use of assistive devices to access tasks ___ Student has prescrictive glasses ___ glasses are prescribed for close work only ___ glasses are prescribed for distance viewing only ___ glasses are prescribed for continuous wear ___ glasses are prescribed for protection from eye injury ___ student refuses to wear glasses ___ may need a new prescription ___ may need to build up tolerance ___ glasses are badly scratched and provide no benefit. ___ Other:
