Iowa Educational Services for the
Blind and Visually Impaired
FUNCTIONAL VISION AND LEARNING MEDIA ASSESSMENTS
(AGES 5-21)
SECTION 1 – GENERAL STUDENT INFORMATION
1. Student Name:
2. Date of Birth:
3. Report Date:
4. Examiner:
5. Assessment Instrument:
6. Assessment Dates:
7. Reason for Assessment:
SECTION 2 – BACKGROUND INFORMATION
1. Setting for Assessment:
2. Previous and Current Vision Services:
3. Other Medical History:
4. Visual History (explain the eye condition including acuity):
SECTION 3 – INTERVIEWS (collects information from various perspectives across multiple settings and
activities)
1. Parent/Guardian Summary and Date:
2. Teacher Summary and Date:
3. Student Summary and Date:
SECTION 4 – OBSERVATIONS (indicates areas of strength and need related to vision in each of these areas)
1. Classroom:
2. PE/Recess:
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3. Orientation and Mobility Observation/Screening/Evaluation:
4. Lunch:
5. Bus:
6. Other:
SECTION 5 – FUNCTIONAL VISION ASSESSMENT
1. Appearance of the Eyes (explains appearance of eyes, social implication, atypical physical symptoms):
2. Peripheral Vision (affects amount of visual information obtained which can result in misjudgments and restriction of movement):
3. Color and Contrast Discrimination (affects ability to distinguish likenesses and differences in color):
4. Light Sensitivity and Preferences (affects individuals differently according to eye condition):
5. Developmental Visual Perception (affects discrimination, perception, reproduction, etc., of shapes, letters, and numbers)
6. Near Acuity and Discrimination (affects ability to read and distinguish objects a near and intermediate ranges):
7. Depth Perception (affects mobility and fine motor skills):
8. Distance Acuity (affects ability to read and distinguish objects at distant and intermediate ranges):
SECTION 6 – LEARNING MEDIA ASSESSMENT
1. Indicators of Readiness:
2. Initial Selection of Learning Media:
3. General Learning Media Current Print Functioning (indicates how printed materials are accessed):
4. Oral and Silent Reading Speed and Comprehension (indicates primary mode of reading):
5. Listening Level (indicates level of listening skills):
6. Computer Monitor Access (indicates access to computer monitor):
7. Near Reading and Writing (indicates if adapted writing materials and/or specialized instruction are needed):
8. Distant Reading and Writing (indicates adapted techniques and materials required for distant work):
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SECTION 7 – SUMMARY
Summary
SECTION 8 – RECOMMENDATIONS
Recommendations
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