Iowa Educational Services for
the Blind and Visually Impaired
ORIENTATION AND MOBILITY ASSESSMENT
IOWA STATEWIDE SYSTEM FOR VISION SERVICES
SECTION 1 – GENERAL STUDENT INFORMATION
1. Student Name:
2. Date of Birth:
3. Parent:
4. Address:
5. Date of Assessment:
6. Date of Report:
7. School or Daycare:
SECTION 2 – ASSESSMENT TOOL (POSSIBLE)
1. Peabody
2. Hill
3. Dodson-Burk and Hill Form A or B
4. TAPS
5. IBS
6. LeVack Low Vision Resource Guide
SECTION 3 – REASON FOR EVALUATION (THINGS TO INCLUDE)
1. Student Age
2. Grade
3. Program at School
4. Medical diagnosis (any and all or just eye information)
5. Visual acuity
6. Doctor’s name (primary or just last seen eye doctor)
O&M Assessment Summary.docx
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7. Report date you are citing
8. Visual field information
9. Any prior O&M history
10. Specific reason evaluation was requested
SECTION 4 – INTERVIEW WITH STUDENT, PARENT, TEACHER (QUESTIONS TO INCLUDE)
1. Where do you go?
2. Where do you want to go?
3. Where are other kids going?
4. Any general safety concerns?
SECTION 5 – OBSERVATIONS (SHOULD INCLUDE INFORMATION PERTAINING TO THE FOLLOWING
CONCEPTUAL SKILLS
1. Body Image
2. Laterality
3. Quantitative Concepts
4. Directionality and Positional Concepts
5. Color
6. Sensory Awareness
7. Mobility Skills: cane travel, sighted guide skills
8. School building/classroom travel (include stairs, elevator)
9. Residential Area Travel and concepts
10. Semi Business Area Travel
11. Business Area Travel
12. Distance Low Vision Device
13. Night Travel (if visual condition and age warrants)
SECTION 6 – SUMMARY
1. General overview
2. Whether or not the student would/could currently benefit from instruction in O&M
O&M Assessment Summary.docx
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SECTION 7 – SUGGESTIONS
 Bulleted list from the above observation
O&M Assessment Summary.docx
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