Download Medical-SPH - Center for Teaching and Learning

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
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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: