SAMPLE REPORT FORMAT

BUILDING LOCAL CAPACITY - QPVI: FLORIDA IMC

ESSENTIAL ASSESSMENTS (EA) FOR

STUDENTS WITH MULTIPLE & VISUAL IMPAIRMENTS (MIVI)

FUNCTIONAL VISION (FVA-LANGLEY DUBOSE)

LEARNING MEDIA ASSESSMENT (LMA – SENSORY LEARNING KIT)

AND EXPANDED CORE CURRICULUM (ECC)

(BASED ON THE ESSENTIAL ASSESSMENTS RUBRIC 2010)

Student: DOB:

School: Grade:

Assessment Date(s):

Evaluator: Teacher of Students with Visual Impairments (TVI)

EYE MEDICAL INFORMATION: Optometrist or Ophthalmologist

The following information has been provided on student’s most recent eye report. (Resource: Looking to Learn, D’Andrea and Farrenkopf,American Foundation for the Blind, 2000)

Ocular history:

Etiology:

Diagnosis:

Visual acuity measures:

Distance

Near

Contrast sensitivity:

Visual field test:

Color vision:

Photophobia:

Muscle function:

Intraocular pressure reading:

Pupillary reflex:

Prescription for corrective lenses:

Prognosis:

Recommended treatment:

Precautions and suggestions:

A. PREPARATION/PLANNING: (Consult EA Rubric content for student’s age or for MI/DB students)

1. Parent/Caregiver Interviews: Input from parent/caregiver is as follows:

2. Classroom Teacher(s)/Service Provider Interviews: Input from classroom teacher is as follows:

3. Student Interview (if appropriate):

STUDENT OBSERVATIONS:Note: Lighting, physical arrangement of natural environment(s), visual clutter, visual behaviors, learning styles, access to media, & classroom behaviors

4. REVIEW OF RECORDS: Note: many of these records will be included in Master List Databasecomprehensive review of:Eye health reports, clinical low vision evaluation (if available), ECC information, academic records, and records from other service providers

B.FUNCTIONAL VISION ASSESSMENT:(Resources: Essential Assessments Rubric,Jose, Blankenship, Siller, Coy, Prause, 2010; ISAVE, Langley 1998; and Functional Vision Screening for Severely Handicapped Children,Langley & DuBose, 1976)

Note: for all results, include any deficits noted and associated recommendations. Consult EA Content Rubric for more detail. Items from the Langley DuBose Screening/ISAVE NOT included in the EA Rubric are in bold face type.

5.Appearance of the eyes: blink reflex, muscle balance, eye preference

Needs(s) noted:

Recommendations:

6.Reaction to visual stimuli: locates or attends to light, tracking ability, reaches for toys, shifts attention, scanning ability, inappropriate visual behaviors

Needs(s) noted:

Recommendations:

7. Informal peripheral fields: Confrontation fields only – 4 quadrants

Needs(s) noted:

Recommendations:

8.Color discrimination and/or preference:

Needs(s) noted:

Recommendations:

9. Figure Ground and/or Contrast Sensitivity: Fixates on object in own hand, selects favorite object from other objects, looks at or points to pictures in books

Needs(s) noted:

Recommendations:

10. Visual Memory: imitation of actions, plays peekaboo, finds partially hidden objects, object permanence.

Needs(s) noted:

Recommendations:

11. Informal Near Visual Acuity: using acuity cards, charts, objects

Needs(s) noted:

Recommendations:

12. Informal Distance Visual Acuity: using acuity cards, charts, objects

Needs(s) noted:

Recommendations:

13. Depth Perception:

Needs(s) noted:

Recommendations:

14. Integration of Visual Motor Processing: approach, match.

Needs(s) noted:

Recommendations:

C. LEARNING MEDIA ASSESSMENTstudent data gathering – infants, toddlers or students with significant cognitive or additional disabilities who are sensory learners

15. SLK FORMS: Learning Media Assessment Components: (Resource:Sensory Learning Kit, APH, 2005. Millie Smith)Report findings from each form as indicated. See pages 45-104 for information andinstructions for each form or use SLK Report Format (sample)

SLK Form 1: Sensory Learning Summary (SLS) (all students): This is a summary of the learner’s individual sensory learning needs based on currently available information.

SLK Form 2: Arousal State Profile (ASP): A range of arousal states are recorded during structured observation, to give a profile of typical patterns of arousal. (Students for whom periods of alertness or responsiveness are in question)

Appropriate/not appropriate:

Results:

SLK Form 3: Sensory Response Record (SRR)(all students): Information about responses to a variety of media in each sensory channel is recorded during structured presentations.

Results: Sensory channels with positive responses noted:

Recommendations:

SLK Form 4: Appetite/Aversion List (AAL)(all students): This list identifies appetite items that elicit positive orienting responses and aversion items that elicit negative orienting responses.

Results: Appetite and aversion items:

Recommendations:

SLK Form 5: Level and Strategy Guide (LSG) (all students): This tool helps determine the appropriate level at which to begin teaching and to identify what specific strategies to use for teaching.

Results:

Appropriate level noted:

Recommendations:

D. PROPOSED ROUTINES

16. PROPOSED ROUTINES from the SLK Routines Book to be implemented by the IEP team (Indicate response level: Quiet Alert, Active Alert, or Partial Participation.

1.

2.

3.

17. KOENIG-HOLBROOK LMA FORM 9 – INDICATORS OF READINESS FOR FUNCTIONAL LITERACY MEDIA (report results if done)

20. PRIMARY AND SECONDARY LEARNING AND LITERACY MEDIAbased on LMA data collected:

THE STUDENT’S PRIMARY LITERACY/LEARNING MEDIA IS:

THE STUDENT’S SECONDARY LITERACY/LEARNING MEDIA IS:

E. EXPANDED CORE CURRICULUM: (resource:Iowa ECC Needs Assessment and various ECC assessments, including the TSBVI EVALS Kit)Student is screened annually across allnine areas of the Expanded Core Curriculum- Assistive Technology, Career Education, Compensatory Skills, Independent Living Skills, Orientation and Mobility, Recreation and Leisure, Self-Determination, Sensory Efficiency Skills, and Social Interaction. Assessment in two to three areas of identified prioritiesshould be completed by TVI, parent, appropriate teachers or service providers. Related IEP goals and instruction are developed unless student is functioning at or above grade level in all nine areas.

21. ECC NEEDS ASSESSMENT RESULTS:

Needs(s) noted:

Recommendations:

22. ECC ASSESSMENT OF PRIORITY NEEDS:

Needs(s) noted:

Recommendations:

23. MEASURABLE GOALS FOR IEP/IFSP (based on FVA/LMA/ECC)

24. CRITERIA FOR ELIGIBILITY STATEMENT: Based on the results of the student’s most recent medical eye examination and Functional Vision Learning Media Assessments,it is recommended to the IEP Team thatthe studentmeets or does not meetcriteria for a program of specially designedinstruction for students with visual impairments.

Evaluator: ______Title: ______

Signature: ______Date: ______

REFERENCES:

Looking to Learn,American Foundation for the Blind, 2000. F.M. D’Andrea and Carol Farrenkopf

Functional Vision Screening for Severely Handicapped Children, 1976. Beth Langley & Rebecca DuBose

Essential Assessments Rubric, 2010. Karen Blankenship, Mary Ann Siller, Jennifer Coy, Julie Prause, Randy Jose

APH Sensory Learning Kit, 2005. Millie Smith

Adapted by: Nancy Toelle (October 2011) QPVI Professional Development: Essential Assessments: FVA, LMA, ECC