Functional Vision and Learning Media Assessments Including Preschool (Ages 3-5)

Iowa Educational Services for the Blind and Visually ImpairedTEACHER INTERVIEW Functional Vision and Learning Media Assessments including Preschool (Ages 3-5)1. SECTION 1 – GENERAL STUDENT INFORMATION 2. Student Name: 3. Date of Birth: 4. Teacher Interviewed: 5. Report Date: 6. Setting: 7. SECTION 2 –MEDICAL HISTORY 1. What do you know about the cause of this student’s impairments? 2. Does the student take medication at school? 3. Does the student seizure? 4. Does anything in the environment (e.g. light, noise, etc.) seem to trigger seizure activity? Yes or No a. Other: 8. SECTION 3 – APPEARANCE OF THE EYES 1. Do you notice abnormalities? a. Eye size: b. Eyelids: c. Eye Contact: d. Watery Discharge: e. Crust: Teacher Interview FVA-LMA Preschool (Ages 3-5).docx Page 1 of 4 f. Excessive Blinking: g. Eye Rubbing: h. Eye Poking: i. Redness: 9. SECTION 4 – EDUCATIONAL PROGRESS 1. What was the last school that served this child? 2. Who was the teacher? a. Telephone: b. Address: 3. Was attendance an issue? Yes or No 4. What are the student’s educational strengths? 5. What are the student’s educational weaknesses? 6. Do they have attentional difficulties? Yes or No 7. What time of day is this student most alert? 10. SECTION 5 – SOCIAL 1. Is this student socially integrated into the class? Yes or No a. Parallel play: b. Group play: c. Independent play: d. Explain: 11. SECTION 6 – PERSONALITY 1. Are there activities that this student particularly enjoys? Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998 by Heartland AEA 11 — Vision Department - 2003 Teacher Interview FVA-LMA Preschool (Ages 3-5).docx Page 2 of 4 2. Are there activities that this student avoids? 12. SECTION 7 – ACTIVITIES OF DAILY LIVING 1. Is he/she able to perform activities of daily living at a level equal to other children his/her age? Yes or No 13. SECTION 8 – VISUAL FUNCTIONING 1. Is this student able to see? Yes or No a. What behaviors do you notice that lead you to answer this way? 2. How does this student function visually in your classroom? 3. Does he/she complain about not being able to see? Yes or No a. Explain: 4. Does this student use a computer in your class? Yes or No a. If so, how far away from the screen does he/she sit? 5. Does this student enjoy reading activities? Yes or No 6. How close does he/she generally hold small objects? 7. Does this student have difficulty in the lunchroom? Yes or No 8. Do you ever notice this child turning their heat to look at objects? Yes or No a. If yes, which way do they turn their head? 9. Do you feel that there are areas of this student’s visual field which are more effective than other areas? Yes or No 10. Do you ever notice this student looking at an object, then looking away before he/she reaches for the object? Yes or No 11. What things does this student look at most consistently? 12. What physical position enables the student to utilize their eyes most effectively? Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998 by Heartland AEA 11 — Vision Department - 2003 Teacher Interview FVA-LMA Preschool (Ages 3-5).docx Page 3 of 4 14. SECTION 9 – ACADEMICS 1. Coloring: 2. Cutting: 3. Seeing demonstrations: 4. Does the student receive support services from other school staff? Yes or No 5. Does the student have an associate or para educator? Yes or No6. Is the student organized? Yes or No 15. SECTION 10 – MOBILITY/TRAVELING 1. Does this student have difficulty traveling in any of the following environments? a. Around the classroom? Yes or No b. Auditorium/Gym? Yes or No c. Playground/Halls? Yes or No d. Stairs? Yes or No e. Keeping oriented to the building (ex: finding the office)? Yes or No f. Cafeteria? Yes or No g. Outdoors? Yes or No h. Other? Yes or No h.i. Please Specify: 2. Does he/she have problems with bright light? Yes or No a. Explain: 3. Does he/she travel independently outdoors? Yes or No a. Explain: Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998 by Heartland AEA 11 — Vision Department - 2003 Teacher Interview FVA-LMA Preschool (Ages 3-5).docx Page 4 of 4

Functional Vision and Learning Media Assessments Including Preschool (Ages 3-5)

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