Iowa Educational Services for the
Blind and Visually Impaired
LEARNING MEDIA ASSESSMENT REPORT
Based on the APH Sensory Learning Kit (SLK)
By Millie Smith
SECTION 1 – GENERAL STUDENT INFORMATION
1. Student Name: _______________________________________________________________________
2. Date of Birth: ________________________________________________________________________
3. School District/School: _________________________________________________________________
4. Dates of Assessment: __________________________________________________________________
5. Assessment Team: ____________________________________________________________________
6. Date of Report: ______________________________________________________________________
SECTION 2 – BACKGROUND INFORMATION
The Learning Media Assessment (LMA) is a required assessment for students with visual impairments,
including those with additional disabilities. The data from the LMA is used to determine the most appropriate
learning/literacy media (learning materials) for the student. Aside from determining if Braille is an appropriate
learning or literacy medium for the student, it addresses, for students with additional disabilities, all sensory
channels, to identify which channels and associated materials are accessible to the student and can be used
for learning. The following data were collected during the SLK assessment and recorded on the Sensory
Response Record.
SLK Form 1:
Sensory Learning Summary (important sensory or medical information used in planning
the assessment):
SLK Form 2:
Arousal State Profile (completed if student arousal periods in question):
SLK Form 3:
Sensory Response Record (results of assessment). This student demonstrated positive
responses regarding sensory items presented.
Responsive Level: The four responsiveness levels identified in the SLK are: extended state (fussy, upset,
angry, and asleep), quiet alert (in a general state of alertness), active alert (alert and
curious about the activity), and partial participation (alert and taking some part in the
activity). This indicates at what level of responsiveness the student performed during the
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assessment and sets the starting point for the level of the instructional activity routines
selected.
(Please indicate # of presentations eliciting responses below)
Total number of items presented:_____
1. Number in Extended State:_____
2. Number in Quiet Alert State:_____
3. Number in Active Alert State:_____
4. Number in Partial Participation State:_____
Total Percentage of items presented:_____
1. Percentage of items in Extended State:_____
2. Percentage of items in Quiet Alert State:_____
3. Percentage of items in Active Alert State:_____
4. Percentage of items in Partial Participation State:_____
List the responsive level most frequently observed:__________________________________________
SLK Form 4:
Appetite/Aversion List (based on assessment)
Appetite Items: These are items presented to the student in all appropriate sensory channels for which a
positive response (liked the item) was demonstrated.
Delayed Response Time: The amount of time it took for the student to respond to the item.
Appetite Items (likes) identified during Sensory Response Record presentations and
average delayed response time per sensory channel:
Appetite items
1. Number in Vest/Prop. (move.):_______
2. Number in Olfactory-observed not tested:_______
3. Number in Gustatory (taste):______
4. Number in Tactual (touch):_______
5. Number in Auditory (sound):_______
6. Number in Visual (sight):_______
Average Delayed Response Time:
1. Average in Vest/Prop. (move.):_______
2. Average in Olfactory-observed not tested:_______
3. Average in Gustatory (taste):_______
4. Average in Tactual (touch):_______
5. Average in Auditory (sound):_______
6. Average in Visual (sight):_______
Sensory channels with the most positive responses:__________________________________________
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Top ten sensory appetite items (Items eliciting strongest positive response): These items
represent appropriate learning media for this student.
1. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
2. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
3. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
4. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
5. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
6. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
7. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
8. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
9. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
10. Appetite Items(likes):_______________________________________________________________
Sensory Channel/Response___________________________________________________________
SLK Form 5:
Level & Strategy Guide (appropriate level & strategies to begin teaching)
Results & Recommendations: Environmental Factors Related To Learner’s Orienting Responses:
Lighting, Temperature, Odors, Noise Level, Visual Clutter, Positioning, Movement, Other: (address all that
apply):
Results And Recommendations: Social Factors Related To Learner’s Orienting Responses:
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Presence or absence of peers/adults, Direct attention to peers/adults, Preferred peers/adults, Others:
(address all that apply):
Recommended Referrals:
Visual, Auditory, Gross Motor, Communication, Medical, Nutritional, Sleep, Dental, Psychological: (address all
that apply):
General Programming Recommendations Based On SLK Results:
Learning Media Assessment Results:
This student responded most frequently on the: ______________ (extended state, quiet alert, active alert, or
partial participation) level of responsiveness. Positive responses to sensory items were elicited in the
following sensory channels: (list sensory channels) :
Appetite items are real objects and activities in the student’s home or educational environment, for which the
student has shown a positive response. Educational programming (activity routines) on the student’s
responsiveness level, incorporating items from the appetite list (above) are recommended as the most
appropriate instructional strategy for this student. Ongoing assessment via additional learning media probes
is recommended.
The following 3 activity routine topics have been selected for this student, based on the assessment data
reported above.
1.
2.
3.
X
Teacher of Students with Visual Impairments
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