LOW VISION CLINIC PRE-EXAMINATION INFORMATION FORM
-Sponsored by The Statewide System of Services to children who are blind/visually impaired-
Please mark the box to the left of the date your child/student will be attending.
LOCATION / DATE / FORMS DUESpring Clinics 2010
- AEA 9, Bettendorf
- AEA 10, Cedar Rapids
- AEA 267, Cedar Falls
- GPAEA, Ottumwa
- AEA 11, Johnston
- AEA 13, Council Bluffs
- NW AEA, Sioux City
.
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.)
______
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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
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HOST SITE INFORMATION:
AEA City Address AEA phone
AEA 10 / Cedar Rapids / 1120 33rd Ave, SW / 1-800-332-8488AEA 9 / Bettendorf / 729 – 21st Street / (563) 359-1371
AEA 267 / Cedar Falls / 3712 Cedar Heights Drive / 1-800-542-8375
GPAEA / Ottumwa / 2814 N. Court Street / 1-800-622-0027
NW AEA / Sioux City / 1520 Morningside Ave / 1-800-352-9040
AEA 11 / Johnston / 6500 Corporate Dr. / 1-800-362-2720
AEA 13 / Council Bluffs / 3501 Harry Langdon Blvd / 1-800-645-2985