Environmental Checklist: 1
MARY T. MORSE, Ph.D.
Special Education Consultant & Certified Teacher of the Visually Impaired
247 Pembroke Hill Road
Pembroke, NH 03275
Phone: (603) 485-7674
Email: marymorsesped@aol.com
Fax: (603)-485-1958
ENVIRONMENTAL CONSIDERATION CHECKLIST
The following factors may or may not have an impact on students and adults who
have CVI or TBI. They are listed to raise awareness that certain aspects of the
environment may need to be modified for specific individuals. It is suggested that
systematic data sheets be used (a) to more accurately determine the optimum
environment to begin therapies and the healing process and (b) prior to
generalizing gains to other situations. Please Note: The word “student” is used
because the author developed and uses this form when providing assessments
within school and home environments. It is hoped the form is equally helpful
when working with adults.
STUDENT:
DATE:
INVOLVED PERSONS
ACTIVITY
1.
Is the environment familiar?
___yes ___no
2.
Is the person working with the student familiar?
___yes ___no
3.
Is the student positioned
•
safely?
___yes ___no
•
4.
in relation to materials and partners such that he/she
can communicate visually, auditorally &/or motorically?
___yes ___no
ROOM CHARACTERISTICS
•
Is the room safe (uncluttered pathways, safe corners/edges,
closed doors/cabinets, no protruding objects,
appropriate size furniture & appliances, etc.)?
___yes ___no
•
Does the room have well defined work areas?
___yes ___no
•
Are there clear paths from one work area to another?
___yes ___no
•
Are the pathways used in a consistent manner?
___yes ___no
•
Are work areas organized, neat, labeled & accessible?
___yes ___no
•
Are there patterns on the
___furniture ___walls ___floor ___ceiling?
•
Does the room seem visually
___organized or ___disorganized
Environmental Checklist: 2
•
5.
6.
DOES THE ORGANIZATION OF THE ROOM PROMOTE ANTICIPATION OF
SCHEDULED EVENTS?
___yes ___no
LIGHTING CONDITIONS : Lighting considerations are not only important as related to
visual conditions but also to states of arousal, both of concern for persons with CVI or
TBI.
•
Is the room
___very bright ___bright ___moderate ___dim ?
•
Is there
___diffuse lighting or a ____focal point of light-e.g., window?
•
Can light sources be individualized and adjusted?
___yes ___no
AUDITORY CONDITIONS
present
absent
•
TV
______________________
•
radio
______________________
•
CD player
______________________
•
air conditioner
______________________
•
clock ticking
______________________
•
phone ringing
______________________
•
appliances (list)
______________________
•
traffic noise
______________________
•
persons moving
______________________
•
people talking
loudly ____
•
Overall impressions of noise conditions
noisy____
softly____
moderate____dim___
intermittent_____ static_____
•
7.
other (list)
____________________________________
STAFF WORKING WITH STUDENT : Persons with CVI or TBI sometimes cannot
discriminate what is important to attend to from what is not important.
•
shirt / blouse
•
sweater
___yes ___no
•
any points of sharp
contrast to shirt
___yes ___no
•
glasses
___yes ___no
patterned____ plain____
color____
Environmental Checklist: 3
•
long earrings
___yes ___no
•
mustache or beard
___yes ___no
•
perfume or cologne
___yes ___no
•
voice tone, volume
___yes ___no
•
hands cold
___yes ___no
•
hands warm
___yes ___no
8.
ROOM TEMPERATURE
9.
Note any unusual ODORS
10.
STUDENT CHARACTERISTICS IS THE STUDENT READY IN TERMS OF
11.
hot___
moderate___
cool___
cold___
•
glasses
___yes ___no
•
hearing aids
___yes ___no
•
auditory trainer
___yes ___no
•
proper position
___yes ___no
•
medical needs met
___yes ___no
•
hunger & toileting needs met
___yes ___no
•
seizure status considered
___yes ___no
•
sensory-motor tolerance considered
___yes ___no
•
fatigue/energy level considered
___yes ___no

other needs
___yes ___no
ACTIVITY CHARACTERISTICS
•
number of stimuli presented
____________
•
on what visual plane
____________
•
size of materials
____________
•
spacing of materials
____________
•
figure-ground contrast
____________
•
motor-friendly materials
____________
•
organization of materials (activity sequence boards)
____________
Environmental Checklist: 4