1867 Frankfort Ave. Louisville KY 40206
(502) 897-1583
Fax: (502) 897-8737
www.ksb.kyschools.us
RTI (Response to Intervention)/Referral Process - Procedures
Suspected Visual Difficulties
INTRODUCTION:
Pages 2-3
LETTERS:
Pages 4-6
Parent/Guardian
4
Eye Care Professional (Includes KY Eye Report Form)
5-6
QUESTIONNAIRES:
Pages 7-16
Teacher
7- 11
Parent/Guardian
12-14
Student
15-16
RTI PROCESS
Pages 17-20
Review of Information Form
17-18
Implementation/Data Form
19
Recommendations/Strategies
20
Gateways 2015
Page 2 of 20
INTRODUCTION
This document was developed to assist school level personnel in making decisions regarding potential
referrals for a suspected visual impairment.
For questions about the document or assistance with educational planning, please contact your local
Teacher for the Blind/Visually Impaired or Kentucky School for the Blind (KSB) Outreach Consultant. To
determine the consultant assigned to your region, contact KSB Outreach at 502-897-1583.
RTI may begin if:

Student fails school entry vision exam or school vision screening

Student exhibits visual difficulties in the classroom

Student’s parent notices visual difficulties

Student has a sudden development OR diagnosis of a visual condition

Student has medical documentation indicating possible vision concerns
Procedures
The following procedures are best practice to be followed before a formal referral for a suspected visual
impairment is made to an Admissions and Release Committee (ARC).
1. Regular Education Teacher (or district RTI personnel) will send informational packet home that
includes these forms:

Parent/Guardian Letter

Eye Report Form

Eye Care Professional Letter
2. Classroom Teacher (or district RTI personnel) will call family to complete the Parent/Guardian
Questionnaire form.
3. Classroom Teacher (or district RTI personnel) will complete the Student Questionnaire form
with student.
4. Classroom Teacher (s) will complete the Teacher Questionnaire form.
5. Teacher of the Blind/Visually Impaired (TBVI) or KSB Outreach Consultant will review all the
information and meet informally with the team (parent, teacher, etc.) to determine the need for
further action.
Use the Review of Information form as guidance to determine proposed actions (choose 1):
A. Confirm that visual difficulties are resolved (ie. obtained glasses, etc.)
B. Discuss recommendations for RTI related to apparent visual difficulties.
Gateways 2015
Page 3 of 20
Use Recommendations/Strategies form as guidance.
Document strategies/interventions and time frames.
Use Implementation/Data form for documentation.
C. Team meeting will turn into an Admissions and Release Committee (ARC).
District due process policies for referral and permission to evaluate will occur.
The evaluation process and RTI implementation will take place simultaneously.
When evaluation is completed, RTI will be discussed as well as the evaluation.
Use Recommendations/Strategies form as guidance. Document
strategies/interventions and time frames. Use Implementation/Data form for
documentation.
6. If action B was chosen, after an agreed upon time of the interventions being in place, the team
will meet to discuss the results. If the modifications were successful, they will be continued and
monitored periodically; no less than yearly. If initial modifications are not successful or at any
point during the monitoring process become unsuccessful, the team shall reconvene and
consider a referral for a suspected visual impairment.
**If the student has a sudden development of a visual condition or new medical diagnosis of a
progressive condition, the school team shall complete steps above and choose action C.
At no time shall the RTI process inhibit or delay the referral process.
Gateways 2015
Page 4 of 20
PARENT/GUARDIAN LETTER (Suspected Visual Difficulties)
Date: _______________
Student Name: _____________________
Dear Parent/Guardian,
The enclosed information has been sent to you because a vision screening or informal observations
indicate a possible vision difficulty.
To determine whether there is a vision difficulty that may affect your child’s education, it is
recommended that your child be seen by an eye care physician for an eye examination.
At your appointment, please have your eye care physician complete the enclosed Eye Report Form. If
your child has already been examined by an eye care physician in the last 12 months please have the
Dr. complete the report to show the results of that particular exam.
Please sign and date the form on the lower back section. We have enclosed an additional letter for the
doctor so that he/she will be able to share this information with the school.
Once completed, the Eye Report Form should be returned to your child’s teacher. Should you have
any questions, please contact your child’s teacher at ______________.
Sincerely,
___________________________________
Gateways 2015
Page 5 of 20
EYE CARE PROFESSIONAL LETTER (Suspected Visual Difficulties)
Date ____________________________
Dear Eye Care Professional,
Vision screening/observations indicate that your patient, _______________________________,
appears to exhibit visual difficulties that may affect his/her educational performance.
In order to determine further action and appropriate educational programming the completed enclosed
Eye Report form in being requested.
We often receive reports that do not include near and distant acuity as well as field of vision. If
acuity is not able to be obtained, please indicate your professional opinion of what the child sees.
It is imperative that ALL sections of the Eye Report are completed.
Please sign and indicate the date of the examination on the back page of the provided Eye Report
Form. Parent signature is also required.
The completed form may be returned to the school via the parent or by faxing to ____________.
Thank you for your cooperation. Should you have questions, please contact _____________________
at this number: ___________________
Consent for Release or Excange of Information
I, _________________________. (Parent/Guardian) give permission to
__________________________ (Eye Care Professional) to release __________________________’s
(Student) medical information to School District Representatives for educational purposes.
Gateways 2015
Page 6 of 20
Gateways 2015
Page 7 of 20
Gateways 2015
Page 8 of 20
TEACHER QUESTIONNAIRE (Suspected Visual Difficulties)
Student Name:
Grade:
Date of Birth:
Teacher:
1. Does the student have glasses or contacts?
2. Does the student wear prescribed lenses?
3. Is there an eye report in the student’s cumulative file?
4. Date on eye report: _________________
5. Please list any medications that the student currently takes:
_________________________________________________
6. Please list any other apparent physical limitations or issues:
_________________________________________________
ACADEMICS
YES NO
NA
Academic performance is commensurate with grade level peers. (if no, please
explain)
Copies information from board, overhead, or Smartboard/ Activeboard with ease and
accuracy
Locates materials consistently in the same spot in the classroom
Uses and reads math manipulatives (ruler, protractor, calculator, etc...) With accuracy.
Attends to visually presented information (circle time, charts/maps, board work, etc.)
Maintains on task behavior when reading or copying
Completes and turns in assignments on time
Keeps materials organized and neat
Uses their finger or marker to keep place while reading
Loses place often while reading
Loses place on cluttered or disorganized worksheets/handouts
Gateways 2015
Page 9 of 20
Rereads or skips lines unknowingly
Reads own handwriting
Maintains an upright posture when reading at desk
Feels objects in order to interpret or understand
Loses interest quickly when reading
Comprehension decreases as reading continues
Other:
HANDWRITING
YES NO NA
Forms shapes/letters/numbers correctly (size & formation)
Consistently writes within and on the lines and within the margins of paper
Consistently lines up math problems
Orients drawings correctly on the page
Consistently uses writing utensil AVOIDING undue pressure to make letters wider or
darker
Consistently spaces words or letters properly on the page
Other:
PHYSICAL
YES NO NA
Squints when reading or accessing materials at near (within 3 ft)
Squints when reading or accessing materials at a distance (beyond 3 ft.)
Rubs eyes after extended reading or focusing
Blinks excessively
Eyes water after reading or focusing for more than 5 minutes
Complains of headaches
Covers one eye when reading or writing
Exhibits excessive touching or pressing of eyes
Exhibits head tilting (eccentric viewing) when reading/writing
Leans/sits closer than 12 inches from paper or book when reading or writing. How
close?
Positions reading materials awkwardly
Describe:
Gateways 2015
Abnormal eye movements
Has one eye that turns in or out at any time
Has large pupils that do not vary with lighting conditions
Appears to be light sensitive around windows and lights
Picks up or turns paper to adjust light or glare
Complains of burning or itchy eyes after reading or desk work
Complains of being unable to see objects/materials/print size
Complains of seeing double
Often complains of nausea or dizziness
Has frequent styes or encrusted eyelids
Responds to facial expressions from 10 feet or farther away
Eyes or eyelids appear reddened
Looks for/retrieves dropped objects
Other:
TRAVEL SKILLS
YES
NO NA
Navigates classroom without stumbling over students or furniture
Transitions from place to place or class to class without getting lost
Avoids bumping/running into peers when transitioning class to class
Maintains pace with other students during transition
Participates in gym or recess
Walks up and down stairs without stumbling/falling/ hesitating
Follows peers without looking down at their feet in a crowded situation
Alternates feet up or down stairs
Visually locates doorknob without searching
Other:
LUNCHROOM
YES NO NA
Eats with utensils instead of hands
Visually locates items on the tray
Visually locates peers in lunchroom
Opens and pours liquids without spilling
Page 10 of 20
Gateways 2015
Page 11 of 20
Independently goes through breakfast/lunch line getting all needed food and supplies
and handling tray
Dumps trash from tray into trash can
Other:
ENVIRONMENT
YES
NO NA
Visually locates person speaking
Visually locates bus line
Has friends that he/she regularly talks to/interacts with
Locates and opens locker without difficulty
Tracks a ball during PE class or recess
Visually locates specific rooms in the building (e.g. bathroom, door numbers, office,
etc.)
Hesitates or trips when flooring changes in texture or color (e.g. White tile to red tile,
carpet to tile, etc.)
Visually recognizes peers in classroom when peer has not spoken
Other:
COMPUTER
YES NO
NA
Moves/tilts screen or positions self closer to screen
Stands to get closer to computer screen
Visually locates and follows the cursor on the screen
Locates keys on keyboard without placing face close to keyboard
Enjoys using the computer
Other:
Please list any additional areas not covered that may be of concern to you:
Gateways 2015
Page 12 of 20
PARENT/GUARDIAN QUESTIONNAIRE (Suspected Visual Difficulties)
Student Name: ___________________________
Date Completed: _________________________ Completed by: ___________________________
It has been brought to our attention that your child has been experiencing some difficulties with their
vision in the school environment.
We would like to collect some information to determine if your child needs further evaluation for visionrelated services at school.
As his/her parents, you have knowledge about your child’s visual functioning outside the school setting.
Please answer the following questions being as descriptive as possible.
Thank you so much for your cooperation. If you have any questions or concerns, please contact me by
email (insert e-mail address) or phone (insert phone number).
Please return to your child’s teacher.
Medical/Physical
1. Has your child been prescribed glasses? If so, does your child wear them? Do they appear to
help?
2. Has your child been diagnosed with a visual condition? If so, what is it?
3. Is your child receiving special treatment for their condition? If so, what is it?
4. Is your child’s eye condition stable or progressive?
5. Is there a family history of vision problems? Please explain.
6. Has your child had eye surgery? If so, what kind? When?
7. Is your child currently taking any prescribed medications? If so, what kinds?
8. What are your concerns about your child’s vision?
Visual Behaviors
1. How does your child explore new objects? (visual. tactual, auditory, or a combination or ways)
2. Does your child watch television?
Gateways 2015
Page 13 of 20
3. How far away from the television screen does your child sit?
4. Does your child like to play computer or video games?
5. How far away from the computer screen does your child sit?
6. Do you notice your child bringing things closer to look at them? Explain.
7. How close does your child generally hold small objects?
8. Does your child have trouble finding food or knowing what is on their plate? Explain.
9. Do you ever notice your child turning their head to look at objects? If so, which way do they turn
their head?
10. Do you feel that there are areas of your child’s visual field (right, center, left, upper, lower) that
they are able to better see? Explain.
11. Do your child’s eyes get tired when they have been looking at or reading something for a period
of time? Describe and tell how long before they feel this way.
Social
1. Does your child have friends?
2. Does your child interact with other children in about the same way as other children their age?
Daily Living
1. Is your child able to perform daily living activities at a level equal to other children their age?
Explain which activities give your child has the most trouble with and which ones they are best
at in the following areas:
 Personal body care

Self-help

Social habits

Housework chores

Recreation/leisure skills
2. What sort of activities does your child enjoy the most?
Gateways 2015
Page 14 of 20
3. What sort of activities does your child avoid?
Academic
1. Does your child read standard print books?
2. What size picture does your child enjoy looking at?
3. Does glare on the page seem to bother your child?
4. How are your child’s listening skills?
5. Does your child follow directions?
6. What educational materials does your child have the most trouble with in school?
7. What subject area does your child have the most difficulty with?
8. Does your child have difficulty completing homework? If so, explain why you think this is so.
Travel Skills/Environmental
1. Does your child complain about bright sunlight?
2. Does your child have trouble getting around in the dark?
3. How does your child adjust to different lighting (going from bright to dark or dark to bright)?
4. Does your child travel independently outdoors?
5. Does your child travel independently in unfamiliar settings?
6. Does your child trip or hesitate on different types of flooring or ground surfaces?
7. How does your child go up and down stairs? Do they alternate their feet?
Please share below any other information you feel is relevant to your child’s visual functioning.
Thank you.
Gateways 2015
Page 15 of 20
STUDENT QUESTIONNAIRE (Suspected Visual Difficulties)
Student Name: ___________________________
Date Completed: _________________________ Completed by: ____________________
1. Tell me about your vision. What can you see? What do you have trouble seeing?
2. What do you like most about school? Why?
3. What do you like least about school? Why?
4. Do you have friends at school? Tell me about them? What do you like to do with them?
5. Are you able to recognize your friends in the hallway? How close do they need to be before you
can recognize them?
6. Do you watch TV? Do you have problems watching it? How close do you get to the TV? What
can you see?
7. Do you have problems seeing information at a distance, ie. Information on board or posters?
Explain.
8. Do you have trouble copying from the board? Explain.
9. Do you have trouble reading and copying from textbooks and handouts? Describe.
10. Do you use enlarged text? Does your teacher enlarge it? Do you know how to enlarge it?
11. Do you use any low vision devices? What do you use? Do they help? Do you like to use them?
12. About how long can you read before your eyes get tired and you need a break?
Gateways 2015
Page 16 of 20
13. Do you have trouble using a computer? Explain.
14. How long can you look at a computer screen before your eyes get tired and you need a break?
15. Do you finish your school work when others finish? Describe.
16. Are you comfortable asking for help when you need it?
17. What kinds of things do you need help with?
18. Do you have good listening skills? Explain.
19. Do you have problems in P.E.? Explain.
20. Can you get around independently in and around school?
Bus
Cafeteria
Playground
Classrooms
Computer Lab
Restroom
Gym
Library
Gateways 2015
Page 17 of 20
REVIEW OF INFORMATION FORM (Suspected Visual Difficulties)
Student Name: ______________________________________
Date Completed: _____________________________________
Eye Report Date: _____________________________________
Eye Condition: _______________________________________
Visual Acuity: __________________________
Visual Field: ___________________________

According to the eye report, even with prescribed lenses, does the student have a visual acuity
of 20/70 or worse in the better eye? ___________


According to the eye report, does the student have a visual field of 20 degrees or worse?
____________
According to the eye report, does the student have a medically diagnosed condition of cortical
blindness? _______________

According to the eye report, does the student have a medically diagnosed progressive loss of
vision (may include: Retinitis Pigmentosa, Glaucoma, Diabetic Retinopathy, Stargardts Disease,
Usher Syndrome, Bardet-Biedl Syndrome, Rod-cone Dystrophy, Cone-Rod Dystrophy, Leber
Congenital Amaurosis, Retinoschisis, Choroidermia, Best Disease, etc.)? Other? __________
___________________________________________________________________________
List Documented Concerns:

Parent Questionnaire

Student Questionnaire

Teacher Questionnaire
Gateways 2015
Page 18 of 20
Proposed Actions:
 Action A. Confirm that visual difficulties are resolved (ie. obtained glasses, etc.)
 Action B. Discuss recommendations for RTI related to apparent visual difficulties. (This option
occurs if the student still appears to have visual issues, but the data collected above does not
reflect the need for immediate referral and evaluation)

Use Recommendations/Strategies form as guidance. Document
strategies/interventions and time frames.

Use Implementation/Data form for documentation.
 Action C. Team meeting will turn into an Admissions and Release Committee (ARC). District
due process policies for referral and permission to evaluate will occur.
o
The evaluation process and RTI implementation will take place simultaneously.
o
When evaluation is completed, RTI will be discussed as well as the evaluation. (This
option occurs when a “yes” answers any of the above questions related to the visual
condition of the student.)

Use Recommendations/Strategies form as guidance.

Document strategies/interventions and time frames. Use Implementation/Data
form for documentation.
Gateways 2015
Page 19 of 20
IMPLEMENTATION/DATA FORM (Suspected Visual Difficulties)
Student Name: __________________________
Classroom Teacher: ______________________
Targeted Area: Suspected Visual Difficulties
Below is a list of recommendations for differentiated instruction from the Teacher for the Blind/Visually
Impaired or Kentucky School for the Blind Outreach Consultant. Please put these into practice and list
any results that you observe.
Strategies/Interventions
Start
Date
End
Date
__________________________________________________
TBVI or KSB Outreach Consultant Signature
Impact/Outcome
Gateways 2015
Page 20 of 20
RECOMMENDATIONS/STRATEGIES (Suspected Visual Difficulties)

Preferential Seating- seating that will vary for each student and requires matching the conditions
that benefit the student to the teacher’s use of the classroom space.

Give notes to student at their desk to copy instead of copying off the board.

Allow student to work with partner

Reading approaches: shared reading, paired reading, echo reading

Materials organized and easily accessible to students

Control background noise

Provide a copy of vocabulary, definitions and examples in advance so student can be familiar
with concepts as they are introduced

Read aloud written information such as board-work, worksheets/handouts, etc.

Have directions recorded so student can listen as many times as needed

Students repeat back directions to ensure understanding

Allow student to record verbal results instead of writing them

Allow student to do worksheets and any writing on computer to increase font size

Allow additional time to complete assignments

Proper lighting

Reduce glare- visors, hats, placement in the room

High contrast markers used on board, posters, etc.

Line guides

Typoscope—blocks out everything on handout except one problem (sentence) at a time.

Write large print on active boards/white boards

Speaker stand in close proximity to student

Use Arial or Verdana font in larger size (handouts, smartboards, etc.)

Eliminate visual clutter on handouts (simplify)

Small group instruction

Time of day for core instruction- avoid visual fatigue

Concrete hands-on experiences

Concrete manipulatives