Iowa Educational Services for
the Blind and Visually Impaired
ORIENTATION AND MOBILITY SCREENING
AGES 3-22
SECTION 1 – GENERAL STUDENT INFORMATION
1. Student Name:
2. Date of Birth:
3. Contact Person:
4. Phone #
5. Report Date:
6. Examiner:
SECTION 2 – BACKGROUND
The student has vision: Yes ☐ or No ☐
Travels independently? Yes ☐ or No ☐
Uses walker ☐ or wheelchair ☐
Has had previous O&M training? Yes ☐ or No ☐
Follows simple commands? (stop, come here) Yes ☐ or No ☐
Use Low Vision Aids? Yes ☐ or No ☐ What?
Participates in extracurricular activities? List:
SECTION 3 – STUDENT AT SCHOOL
Travels independently in class? Always ☐
Sometimes ☐
Never ☐
Maintains orientation traveling to:
Classroom(s) Always ☐ Sometimes ☐ Never ☐
Restroom
Always ☐ Sometimes ☐ Never ☐
Office
Always ☐ Sometimes ☐ Never ☐
Cafeteria
Always ☐ Sometimes ☐ Never ☐
Gym
Always ☐ Sometimes ☐ Never ☐
O&M Screening Ages 3-22.docx
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Travels independently on campus?
Utilizes problem solving skills?
Always ☐ Sometimes ☐ Never ☐
Always ☐ Sometimes ☐ Never ☐
Negotiates familiar routes:
Independently
Always ☐ Sometimes ☐ Never ☐
With Assistance
Always ☐ Sometimes ☐ Never ☐
SECTION 4 – PROBLEM AREAS
☐ Difficulty with steps, stairs, drop-offs
☐ Bumps into objects and people
☐ Trouble adjusting to light changes
☐ Difficulty with gym
☐ Trouble with glare/shadow
☐ Other
SECTION 5 – COMMUNITY (Discussed with appropriate person: parent, student, guardian, etc.)
Travels independently:
In neighborhood
Always ☐ Sometimes ☐ Never ☐
In community (malls, grocery store)
Always ☐ Sometimes ☐ Never ☐
Utilizes public transportation:
Always ☐ Sometimes ☐ Never ☐
SECTION 6 – PROBLEM AREAS
☐ Difficulty with steps, stairs, drop-offs
☐ Difficulty with uneven surfaces
☐ Difficulty traveling at night
☐ Difficulty crossing streets
☐ Sensitivity to sunlight
☐ Frequently gets lost
☐ Other
Comments/Concerns:
O&M Screening Ages 3-22.docx
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SECTION 7 – VISUAL DEVELOPMENT MILESTONES-CHECKLIST

0-12 months Response to light, visual awareness, focus tracking, fixation, accommodation

1-3 years
Discrimination of lines, angles, shapes, color identification of common objects,
people recognition, assemble simple puzzle.

4-5 years
Relationship in space and distance (2 dimensional); representation of abstract,
figures and symbols, movement gauges, figure ground:
SECTION 8 – TASK ANALYSIS
1. Describe task:
☐ Near – ☐ Distance ☐ Both: other
2. Time required completing task:
3. Illumination:
SECTION 9 – MOBILITY TASKS
1. Moves with assistance:
☐ Yes
☐ Distance
☐ Both: other
2. Moves independently:
☐ Yes
☐ Distance
☐ Both: other
3. Purposeful in movement:
☐ Yes
☐ Distance
☐ Both: other
4. Oriented as moves:
☐ Yes
☐ Distance
☐ Both: other
5. Safely moves in environment:
☐ Yes
☐ Distance
☐ Both: other
6. Makes accommodations:
☐ Yes
☐ Distance
☐ Both: other
7. Device needed/introduced:
☐ Yes
☐ Distance
☐ Both: other
Michigan Severity Rating Scale Score:
Recommendation level of service:
Amount of time:
Additional comments:
O&M Screening Ages 3-22.docx
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