Delete All Highlighted Information Upon Completion and Submission of Report

DELETE ALL HIGHLIGHTED INFORMATION UPON COMPLETION AND SUBMISSION OF REPORT YOUR DISTRICT AND CONTACT INFORMATION

Functional Vision Learning Media Assessment (FVLMA) and Expanded Core Curriculum (ECC)

Personal Data: Name: Date of Birth: School: Age: Grade: Assessment Date: finished report? District: Assessed by: Parent/Guardian: Address: City, State, Zip: Phone:

Review of Records and General Information: Reason for assessment, IEP minutes if already receiving services 60 mpw, PT 2X) , description of all current and past services, school attendance, grades, past medical info., surgeries, diabetic or other medical conditions, medications, side effects, explain diagnosis, ongoing academic assessment and progress, ongoing functional skills assessment and progress, initial or ongoing KSB services, if receiving O&M services or other services – describe extent and progress, discuss overall skills related to disability(s).

Parent Interview: use interview form and conversations with parents

Student Interview: use interview form and conversations with student, include activities that student is involved in

Teacher Interview: use interview form and interview more than 1 teacher, good to interview all teachers due to varied environments

Assessment Instruments, Materials, and Strategies (Only List WHAT YOU ACTUALLY USE: ADD TO OR DELETE) These are ONLY EXAMPLES Classroom/school environment observations Skills checklists/inventories Structured assessment  Reading and Writing Behaviors Checklist Lighthouse Near Acuity Test  Tactual Perceptual Skills Feinbloom Distance Acuity Test Parent, Teacher,  Literacy Tools Devices & Modifications and Student Interview Inventory Review of Records  Continuing Assessment of Literacy Media Natural and Teacher Made Materials  Burns & Roe Informal Reading Inventory Literature book (for extended time reading rates)  Minnesota Braille Skills Inventory Computer based iPad iPad Apps

Medical History Information: Eye Care Specialist Clinical Low Vision Functional Vision MD – Ophthalmologist OD – Optometrist Name: Student Name Functional Vision & Learning Media Assessment & ECC page 2/5

Date: 2. Visual condition: Primary: Secondary: 3. Age of onset: 4. Stability of visual condition: Stable Deteriorating Improving Uncertain 5. Acuity (As reported by Dr. name here) Distance Near Without With Correction With Low Vision Without With With Low Correction Device Correction Correction Vision Device OD: OD: OD: OD: OD: OD: OS: OS: OS: OS: OS: OS: OU: OU: OU: OU: OU: OU: OD = Right Eye OS = Left Eye OU = Both Eyes 6. Visual fields: 7. Prescription lenses: Sph. Cyl. Axis OD -.___ +______ Document if no prescription or no information available. Delete script information if not OS -.___ +______ needed. Date prescribed: 8. Other references to visual functioning: take from eye report - (lighting requirements, PE, stairs) 9. Medications: list ALL present medications and recent past ones 10. Additional disabilities: (i.e. sensory, motor, cognitive) FUNCTIONAL VISION A Functional Vision Assessment is an organized plan for observing how students use their vision to perform routine tasks in familiar and unfamiliar environments and to what extent this impacts learning and performance. NOTE: familiar and UNFAMILIAR environments – need to include many observations to cover student visual functioning from arriving at school to leaving school to other environments as much as possible – can include family input on how student functions in environments outside of school settings, just document who reported what…

We need to use CONCRETE testing tools – cannot simply use professional judgment Physical appearance and eye movement:  Blink Reflex:  Muscle Balance:  Eye Preference:  Convergence:  Shifting:  Scanning:  Tracking:  Photophobia:  Pupil Response:  Other:

Color Discrimination:

Confrontation Functional Peripheral Fields:

Contrast Sensitivity:

Observations of functioning in near visual tasks up to 16 inches: 16 inches is typical reading distance – near vision chart has string that measures to 16 inches

Observations of functioning in intermediate visual tasks from 16 – 36 inches: Student Name Functional Vision & Learning Media Assessment & ECC page 3/5

Observations of functioning in distance visual tasks beyond 3 feet:

Depth Perception: Document concerns in functional terms and also document if student failed or passed formal depth perception tests. Can document as having “limited depth perception” and then explain. NEVER document that a child has NO depth perception. Everyone who has vision has some degree of depth perception, even if there is only vision is one eye. The degree of good depth perception is what is questionable.

Visual perceptual skills: Document reported and observed issues in functional terms (reading, math, dyslexic-like behavior). Use formal TVPS (Test of Visual Perceptual Skills) to attain more accurate skills. Visual Ground Visual Memory Visual Sequential Memory Visual Closure Visual Spatial Relationships Visual Discrimination Form Constancy LEARNING MEDIA A Learning Media Assessment encompasses the selection of learning and literacy media for students with visual impairments. Learning media refers to the types of materials methods or modifications that a student uses in conjunction with the sensory channels (visual, tactile, and auditory) to obtain information and gain meaning. Literacy media refers to the range of tools for reading and writing in print and Braille.

Use of Sensory Channels: Assess to determine Visual, Tactile, Auditory, or a Combination. Document how you were able to determine.

Indicators of Readiness for a Conventional/Functional Literacy Program:

Formal Reading and Listening

Reading Efficiency: COPY AND PASTE TO ADD MORE CHARTS AS NEEDED Mode of reading means: (with or without glasses, large/regular print, print size, contrasting background, braille, etc.)

Mode of reading: document mode and explain exactly what student looked like and did here, posture, distance from material, etc.

Reading Level Type Comprehension Rate

Mode of reading:

Reading Level Type Comprehension Rate

Student Name Functional Vision & Learning Media Assessment & ECC page 4/5

ATTACH AND USE AVERAGE READING RATES CHARTS TO SHOW AND EXPLAIN VAIRANCES IN STUDENT’S ABILITY AS COMPARED TO SAME AGE PEERS. PURPOSE OF DETERMINING READING RATES IS TO DETERMINE WHAT STUDENT NEEDS TO BE ABLE TO PERFORM AS SAME AGE PEERS

Based on the reading rate tables attached to this report, it appears that XXXX is/ is not reading at levels commensurate with same age peers….. EXPLAIN

Listening Comprehension:

Reading Level Comprehension

Based on assessments of Listening Comprehension, it appears that XXXXX’s listening comprehension levels are/are not as same age peers.

Functional Reading and Writing Skills

TAKE ALL THIS WORDING OUT IF IT DOESN’T PERTAIN TO STUDENT Tactual/Braille Skills: Braille Skills Inventory comments: OR Using only his/her sense of touch, XXXX was able to:  Identify familiar toys, objects  Sort two kinds of tactually dissimilar objects  Explore tactual books  Sort two kinds of similar objects  Match and identify textures  Match and identify shapes  Identify raised shapes that are the same and different  Identify raised line shapes that are the same and different  Track raised lines and lines of braille cells from left to right  Identify braille configurations which are the same and different  Locate one grossly different, moderately different, or slightly different braille configurations in a horizontal row of 5 configurations  Count the number of configurations with a specified dot pattern in a double spaced row of ten grossly different configurations.

Comments:

Handwriting: include handwriting samples, varied pencils and types of paper used, eventually may need to use keyboard as written tool for communication, etc., what tools did you use that enabled student to perform at a higher level related to handwriting, think about being able to write signature even

Expanded Core Curriculum Needs Assessment EVERY STUDENT MUST HAVE SOMETHING IN EVERY AREA(USE ECC CHECKLISTS) from various sources – this area will guide IEP PLEP and GOALS

Assistive Technology: documentation here may lead to need for more extensive AT Evaluation Career Education: Student Name Functional Vision & Learning Media Assessment & ECC page 5/5

Compensatory Skills: Recreation and Leisure: Orientation and Mobility: documentation here could lead to recommendation for O&M Evaluation Self Determination: Social Interaction: Sensory efficiency: Independent Living:

Other Observations to Note:

SUMMARY OF MAJOR FINDINGS

Address the need for Braille Instruction ALWAYS USE “APPEARS” Add SUMMARY STATEMENT: Based on the evaluation information collected across multiple settings and sources, XXX appears to have visual functioning that adversely affects his/her educational performance as summarized above. It is recommended that XXX be considered by the Admissions and Release Committee to be eligible for services as a student with a visual impairment. RECOMMENDATIONS The following recommendations, based on compiled assessment information, may be beneficial to the student’s educational program.

  BE SPECIFIC AND TO THE POINT  CATEGORIZE IF NEEDED  ALWAYS INCLUDE KSB SHORT TERM OPPORTUNITIES  RECOMMENDATIONS FOR OTHER SERVICES LISTED HERE, SUCH AS O&M, PT, OT  RECOMMENDATIONS FOR FURTHER EVALUATION (OM, AT, CLINICAL LOW VISION EVALUATION, ETC.)  KIMRC

Your Name, Teacher for the Blind and Visually Impaired Date _____XXX____Schools Your school address and contact information