______________ INDEPENDENT SCHOOL DISTRICT
FUNCTIONAL VISION EVALUATION
LEARNING MEDIA ASSESSMENT
Student Name: Date(s) of Evaluation:
DOB:
Campus:
Evaluator:
Title:
I. ELIGIBILITY STATEMENT
Based on the most current report from an eye specialist and the results of the Functional Vision Evaluation, this student (appears/does not appear) to meet eligibility as visually impaired as defined by the
Commissioner's/State Board of Education rules. The student's visual impairment adversely affects/does not adversely affect the student's educational performance. This student seems to have the necessary visual components to learn from her environment without visual modifications, and does not qualify for VI services.
II. PURPOSE OF EVALUATION:
This student was referred for an Initial Function al Vision Evaluation and Learning Media Assessment to determine qualification and educational need for services from a teacher of the visually impaired.
OR
This student was referred for a Functional Vision Re-evaluation and
Learning Media Re-assessment to determine qualification and educational need for (continued) services from a teacher of the visually impaired.
III. BACKGROUND INFORMATION and MEDICAL HISTORY
This student is a --- year old attending --- grade at --- School. The most recent FVE/LMA was dated ---, and at that time she/he qualified / did not qualify for VI services. She/he has been receiving vision consult/ direct services for the school year ---. Attached are the VI goals and objectives written at the last ARD dated---, showing level of mastery attained.
This student was most recently seen by Dr. --- in --- on ----. The eye exam report indicates that this student has a diagnosis of ---, with the etiology of ---, and the prognosis is ---. The visual acuity was measured at 20/ --- near and 20/ --- distance, with best correction,
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and with both eyes together ( if there is only info about each eye separately, state each of those visual acuities ). There is no/an apparent field loss, color vision is not normal, and the student is not legally blind. It was indicated that this student does not have a serious vision loss after correction, and recommendations made include ---. This student has a progressive medical condition that will result in no vision or a serious visual loss after correction.
There is no other significant medical information. (
IV. FUNCTIONAL VISION EVALUATION
If there is, state that information here, and the resulting implications )
A.
Sources of Data:
The following assessment tools and/or procedures were used to evaluate the student's functional vision.
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Snellen Eye Chart (distance) or ___________
Lighthouse Distance Chart for Children
Lighthouse Flashcard Test for Children (distance)
Lighthouse Near Vision Test
Lighthouse Near Vision Number Card
New York Near Vision Test
Good-Lite Reading Cards
Barraga Visual Efficiency Scale
Oregon Project
Growing Up
Basic Reading Inventory
Sloan Reading Cards
Diagnostic Assessment Procedure (DAP)
Functional Vision Protocol:
Learning Media Assessment Protocol:
Informal assessment techniques and tools o o visually stimulating toys/materials other sensory stimulating toys/materials o o o print samples student/teacher interview observations other assessment tools: o
B.
Environments:
The student was observed in a variety of environments.
(List the environments)
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C.
Physical/Optical: (Write the results of the following paired up appropriately in paragraph form)
 Appearance of eyes was normal / abnormal and pupil response was not normal in both eyes
 The student exhibited did not exhibit a normal blink response to hand movement
 Visual attention to, awareness of the environment, and localization was shown by ------ Exhibited attention to moving/stationery objects
Light perception was observed by ---. 
 Student showed / did not show evidence of eye contact
 Student was not able to fixate on ----- and nystagmus was not present
 There was no evidence of muscle imbalance
 Student was able to track / had difficulty tracking/ did not demonstrate smooth tracking, horizontally, vertically, circularly, with / without slight head movement. Did not demonstrate smooth tracking across midline, but did follow objects with eyes and relocate them as they moved along her line of vision.
She could follow --- very slowly, moving her head to accommodate for field loss in the --- quadrant.
 There appeared to be no visual field loss. -----. She showed normal peripheral vision in all quadrants. She definitely / tended to / appeared to prefer using her ---visual field to view -
-- (toys, people, and her environment). She tilted her head --- when looking at or
 The student showed the ability to shift gaze in all quadrants, and from near to far
 Convergence was not exhibited and there seemed to be a right
/left eye dominance
 Depth perception was not within normal range
 Binocular vision was shown to be -----
 Near visual acuity was measured at 20/ with both eyes at --- inches, and distance visual acuity was measured at 20/ with both eyes at --- feet. These findings are not concurrent with the eye doctor’s findings.
 This student demonstrated good/poor visual scanning by -----
 Preferred working distance seemed to be ----
 Response to visual clutter
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 Visual closure strengths included -----
 Visual closure weaknesses included ----
 She was able to show / showed good/poor visual discrimination by matching ----
 When engaged in visual motor activities, she was not able to ---
 Visual memory was a strength / weakness
 Through the evaluation visual endurance and fatigue was not a factor
D.
Reading and writing at near:
The student recognizes letters and a few words (for example: ), but is not reading at this time. The student is able to see and use ---- point print at ---- inches. She seems to prefer ---color print on ---- color paper. She can see and use the current classroom texts, including ----.
She’s able to identify money in coins and bills, and can read daily living materials including -----
She can trace with her finger / a writing tool ----. She can copy/draw/write the following: ------, using regular pencil and paper/ using ---------. To adjust to near tasks, she -------.
This student’s preferred handwriting appears to be print/cursive/keyboard, using regular pencil and paper, bold line pens, bold line paper, signature guide, slate & stylus, brailler, ----. She cannot read her own handwriting, and cannot sign her name legibly.
E.
Mid-Range to distant tasks:
The student can transfer written material from ------- with/without using any low vision tools. She is not able to read writing from a board or overhead, from a distance of no more than ----. She can benefit from the use of ------in the classroom, and needs preferential seating
(explain). She’s able to locate and identify ----- in the school environment.
F.
General Mobility
Indoor visual functioning was observed in the classroom, hallways, and gym. The student is not independently mobile, is not oriented to -------
, and uses visual/auditory/tactual clues to avoid stationery/moving objects before contact. She does not trip or fall over objects in her periphery, and is not able to use stairs and/or ramps. Lighting available
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was ---. This did not seem to affect the student’s functional vision negatively OR the student functioned better in dimmed/bright lighting conditions, such as in the ---- as opposed to ----. Glare did not seem / seemed to be an issue.
Outdoor visual functioning was observed around the campus, the school parking lot, the playground. Lighting conditions included a cloudy day, bright sunlight, dusk light. She was able to identify/detect ---- from a distance of ---. The student demonstrated some difficulty when ----. She is also not able to adjust to lighting changes when moving from outdoors to indoors, and vice versa. The student had no difficulty in getting around independently, navigating curbs and stairs with/without difficulty.
V. LEARNING MEDIA ASSESSMENT
A.
Primary & Secondary Sensory Channel
Based on the Functional Vision Evaluation, student behaviors, teacher interview and the eye doctor's report, (student name)'s primary sensory channel for learning is ______ with _________ as the secondary learning mode. (visual – tactual – auditory)
B. Learning Media
Thus, the following instructional materials and strategies will be appropriate for this student: (Write in paragraph form)
__ auditory instruction,
__ auditory materials,
__ braille materials and texts,
__ large print books, maps and worksheets,
__ concrete manipulative objects,
__ materials from kits such as -----
__ hand-under-hand modeling,
__ tactual charts and maps,
__ the same materials provided sighted peers,
__ other
C. Literacy Medium
Therefore, (student name)'s will (choose one to fill in sentence)
utilize visual learning media
utilize auditory learning media
utilize tactual learning media
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as a primary tool for learning to be able to communicate in both reading and writing at the same proficiency as other students of comparable ability.
Based on the Learning Media Assessment, he student’s most appropriate reading media is (choose one to fill in sentence)
 regular print ___ but requires/ and does not require ongoing evaluation.
 is large print,___ but requires/ and does not require ongoing evaluation.
 is unknown at this time because the student is an infant; ongoing evaluation is required.
 is not applicable as the student is a non-reader at this time, therefore ongoing evaluation is/is not required.
The student’s most appropriate writing media (choose one to fill in sentence)
 is pen/pencil and paper/keyboarding/dictation, but requires/ and does not require ongoing evaluation.
 is unknown at this time because the student is an infant, and ongoing evaluation is not required.
 is not applicable as the student does not have the physical ability to write, and ongoing evaluation is not required.
 is undetermined based on current functioning level and ongoing evaluation is not required.
The student may need to use _____ media as a secondary learning tool, based on fatigue factors.
D. Based on the Functional Vision Evaluation and Learning Media
Assessment, this student is not functionally blind by TEA definition, as the student will not use tactual as a primary tool for learning to be able to communicate in both in reading and writing at the same level of proficiency as other students of comparable ability.
This student is unlikely to need to use Braille in the future.
This student has a progressive eye condition and the need for Braille instruction will require ongoing evaluation and monitoring.
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The student is a tactual learner, but functioning at a level such that instruction in pre-braille, braille readiness, braille reading and writing or tactual symbols is not appropriate at this time. Reading and writing medias are inappropriate at this time.
This student is functionally blind.
Her pre-braille/ braille readiness skills are strong in these areas: Is not tactually defensive, explores objects tactually, tactually discriminates between objects, tactually discriminates between shapes, counts to six, has / does not have one to one correspondence, and demonstrates the concept of same and different. Weaknesses in this area include: (from the previous sentence)
OR—
Her Braille reading and writing skills are strong in: (choose from below to fill in sentence), and weak in: (choose from below to fill in sentence)
 identifying braille cells as same and different
 identifying __________letters of the alphabet
 knowledge of grade 2 Braille contractions
 grade level reading speed
 grade level reading comprehension
 appropriate finger/hand positioning and use
As shown in the chart below, the student showed best efficiency of reading (Words per Minute/Comprehension) with Regular Print, Regular
Print with magnifier or other low vision device, Large Print, Braille.
BASIC READING INVENTORY as USED for LMA: SUMMARY
Working
Distance
Regular Print
Regular Print with Line Guide
Regular Print with ___X Magnifier
Regular Print with CCTV
Large Print
Grade
Level
Braille
Silent
Auditory
WPM Comprehension
Level
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VI. EDUCATIONAL IMPLICATIONS
Write 1-2 paragraphs regarding some of the ideas below:
According to the results of this evaluation procedure, this student’s visual impairment affects methods of instruction and modification of materials in the following ways:
 Implications for educational placement
 Size of print
 Distance
 Lighting
 Methods of instruction due to visual impairment
 Modifications in materials due to visual impairment
 Recognizing that this does not respond visually to activities beyond a distance of ----, it is important to present objects and activities close to her. Because of her limited visual field, objects need to be presented on her ---- side.
 This student requires modifications for participation /to benefit from/ in PE class, field trips, of class assignments and /or tests, modified seating arrangements, of lighting, writing, reading, use of tech devices to fully participate in the educational process, specialized skills training, to accommodate visual fluctuation
VII. RECOMMENDATIONS (choose the applicable)
 This student continues to meet the eligibility criteria as visually impaired under the State Board of Education guidelines, and the ARD committee should consider registering him with the Texas Education
Agency.
 This student’s visual impairment does not adversely affect his/her educational performance, and therefore he/she does not meet the eligibility criteria as visually impaired.
 The student’s vision should be rechecked as recommended by the eye doctor.
 Registration and/or continued communication are needed with the following services in order to obtain textbooks, educational aids, consultative and technical assistance. o DARS, for children's services, educational aids, vocational training o American Printing House for the Blind, for materials available on quota funds, including textbooks in braille, large print o Recording for the Blind or RFB&D, for taped textbook materials
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o Texas State Library, for supplemental reading materials and equipment at home and/or at school.
 It is recommended that this student receive services from a teacher for the visually impaired who can provide consultation about her visual needs to the family and other professionals involved in her program. It is recommended that the VI services be Direct /Consult
/Monitor for a minimum of ---minutes/---Xs/ week/6 weeks/months/year. Goals should address the areas of: ----
 A Clinical Low Vision Evaluation appears to be warranted at this time.
 A Clinical Low Vision Evaluation does not appear to be warranted at this time, as the a. student is a non-reader. b. student's educational programming does not require low vision
devices at this time. c. student currently does not have the motoric ability to handle low
vision devices. d. student has a low vision report on file dated . e. other
 An Orientation and Mobility Evaluation and/or services should /should not be
. requested at this time. (If not, state why)
 This student should be able to benefit from opportunities to use regular print with without magnification, enlarged print, auditory materials, tactile materials, multi-sensory materials, which seems to be the appropriate learning and literacy media determined for her at this time. OR Ongoing assessment/evaluation is needed to best determine the appropriate learning and literacy media.
 Braille instruction should be considered as a means for literacy.
Therefore, an ongoing assessment of literacy medium is warranted by a teacher of the visually impaired for efficiency of information.
 Adaptations/Modifications such as the following are related to the student’s visual impairment and need to be considered: ----
 Comprehensive Individual Assessment: the diagnostician will need to consult with the TVI to discuss any modifications or adaptations necessary, such as low vision aids, print size, lighting, use of high contrast.
 State testing considerations include ------
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It was a pleasure to be involved with in this student’s evaluation. (state reason)
Evaluator’s signature, letters of title
Title in words
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