LOW VISION CLINIC PRE-EXAMINATION INFORMATION FORM -Sponsored by The Iowa Educational Services for the blind and visually impaired
Please mark the box to the left of the date your child/student will be attending.
LOCATION DATE FORMS DUE
NW AEA Sioux City September 19,2012 September 12, 2012 AEA 10 Coralville October 10, 2012 October 3, 2012 AEA 10 Cedar Rapids October 17, 2012 October 10, 2012 AEA 1 Dubuque November 7, 2012 October 31, 2012 AEA 267 Clear Lake November 28, 2012 November 22, 2012 GHAEA Council Bluffs January 16, 2013 January 9, 2013 GPAEA Ottumwa February 6, 2013 January 30, 2013 AEA 11 Johnston February 13, 2013 February 6, 2013 AEA 11 Johnston February 20, 2013 February 13, 2013 AEA 9 Bettendorf March 6, 2013 February 27, 2013 AEA 8 Fort Dodge March 20, 2013 March 13, 2013 Make up date - TBA March 27, 2013 TBA .
Today's Date AEA Student's Name DOB Sex __M __F Parent's Name ______Address: ______Parent's Daytime Phone ____ Home Phone (if differs): ______Cell (optional): ______Teacher of Students with Visual Impairments Certified/licensed Orientation and Mobility Specialist ______Has the student been seen at an IBS-sponsored low vision clinic before? __ Yes __ No
Date of last low vision clinic: ______
Date of last eye exam ______Current eye doctor: ______
VISUAL FUNCTIONING – to be filled out by TVI along with parent(s): Diagnosis causing vision loss: ______Does the student use any optical devices? __ Yes __ No If yes, please list: ______Does the student use any assistive technology? __ Yes __ No If yes, please list: ______
What information would you like from this evaluation? (e.g. assessment of visual functioning, recommendation for low vision devices, glare control, driving questions, etc.) ______Page 2 of 3
EDUCATIONAL INFORMATION - to be filled out by TVI along with parent(s):
School Name School Address School City, State, Zip School Phone Student’s Grade or School Placement Student’s Achievement Level Does the student have any additional disabilities? __ Yes __ No If yes, please describe: ______
MOBILITY Do you have any concerns about your student’s orientation and mobility skills? __Yes __ No If yes, please list concerns: ______
Does the student currently receive O & M services or is there a plan to review the need for O & M services? __ Yes __ No
OCULAR HISTORY 1. If you have a current report from your child’s eye doctor, you may send us a copy of the report. Please send the eye doctor report along with this information form. OR 2. If you do not have a current report from your child’s eye doctor, then sign the Release of Information on page three of this form and have your child’s eye doctor provide us a copy of his/her own report form or narrative report. The information should be returned to the address at the bottom of the form.
**Please attach current functional vision evaluation (TVI)** Page 3 of 3
Consent
A report of the Low Vision Clinic evaluation will be sent to you (parent/guardian). Your signature below permits us to send a report copy to your area education agency and your child’s school. Additionally, we will send copies to other individuals or agencies as you wish, if you provide the name and complete mailing address.
Name Address City, State, Zip
Name Address City, State, Zip
Release Of Information I hereby authorize the release of the above information to:
Low Vision Clinic / Iowa Braille School 1002 G Avenue Vinton, IA 52349
______Parent Signature Date:
Email address (optional): ______
Return this form by date due prior to clinic to:
Pat Barr Low Vision Clinic Iowa Braille School, 1002 G Avenue, Vinton, IA 52349
Please direct questions or concerns to: Jim Judd, Low Vision Clinic Coordinator 319-472-5221, Extension 1050 [email protected]
------cut & save------HOST SITE INFORMATION: AEA City Address AEA phone AEA 10 Cedar Rapids 1120 33rd Ave, SW 1-800-332-8488 AEA 9 Bettendorf 729 – 21st Street (563) 359-1371 AEA 267 Cedar Falls 3712 Cedar Heights 1-800-542-8375 Drive GPAEA Ottumwa 2814 N. Court Street 1-800-622-0027 NW AEA Sioux City 1520 Morningside 1-800-352-9040 Ave AEA 11 Johnston 6500 Corporate Dr. 1-800-362-2720 AEA 13 Council Bluffs 3501 Harry Langdon 1-800-645-2985 Blvd