Student Screening Form

eDescription Project

Confidential Screening Questionnaire

To be Completed by the Teacher

Thank you for showing interest in the eDescription Project. The following information is necessary in deciding if your student is appropriate to take part in this research study. Please feel free to add as much information as you want. You may use the backs of the pages if necessary.

There are many students who will be participating in this study. You may find that some questions are not applicable to your student. If you come across such a question, please write NA (Not Applicable). We will review the questionnaire to make sure we understand all your answers and may contact you for clarification.

Information collected here or in later stages of the project will not be identified with specific students. Use of identifying information would only be done with the written consent of the student's parent or guardian. The last page of this questionnaire is a release of information form. It is essential that this form be completed and signed by the child’s parent or guardian.

When complete please e-mail to

Or mail to: WGBH/NCAM125 Western Avenue, Boston, MA 02134

Today's Date: ______

Basic Demographic Information

I. Vision Professional's Information

Name: ______

TVI

COMS

Other ______

Home Phone: ______

Work Phone: ______E-Mail: ______

Mailing Address: ______

I am currently the student's:

TVI

COMS

Other

How long have you worked with this student? ______

II. Student Information

Name:______

Nickname:______Date of Birth: ______

Male

Female

Language used at home: ______

III. Educational History

Present School:

Name______

Address______

School's Contact Person: ______

School's Phone Number: ______

Public

Private

Residential

Day

How many years in this school?123456NA

Comments: ______

Present Grade in School:2345NA

Is student working roughly at grade level in all subject areas other than math and science?

Yes

 No

If not, what is the grade level of students' work? ______

Does the student's present work vary greatly among subject areas?

Yes

No

If Yes, Describe______

Does this student have a one to one aide?

Yes

No

What is this student's primary reading medium?

Braille

Print

Audio

What is this student's secondary reading medium?

Braille

Print

Audio

IV. Clinical Visual Information

Etiology-Eye Condition/s______

______

Age at onset: ______

Age at diagnosis: ______

Clinical Acuity: ______OS______OD______OU______

Date of last clinical vision test: ______

V. Functional Vision

Right Eye (OD) Left Eye (OS)

No light perception

Light perception

Sees some shapes and forms

No light perception

Light perception

Sees some shapes and forms

* If student has no functional vision skip to section VII.

Near: reads ____pt. print @ _____ inches. Font?______

Low Vision Aids Used: ______

Comments: ______

Distance: reads license plate @ ______feet.

Comments: ______

Functional Fields (diagram or describe)

OS______

OD______

VI. Documented Developmental Delays(please check those that are appropriate)

none

receptive language skills

expressive language skills

fine motor

gross motor

social skills

cognitive development

self care

other ______

If you indicated any above, please describe: ______

Additional Impairments

Yes

No

Describe: ______

VII. Medical History(please check those that are appropriate)

Health status

Comments: ______

Current medications

Comments: ______

Serious illnesses

Comments: ______

Accidents

Comments: ______

Head injuries

Comments: ______

Convulsions/seizures

Comments: ______

Allergies

Comments: ______

We appreciate the trouble you have taken to fill out this form. Your answers will help us decide if your child is an appropriate candidate for the E-Description study. Thank You.

Please e-mail completed forms to:

Or mail to: WGBH/NCAM

125 Western Avenue

Boston, MA 02134

Attention: Terry Maggiore

To be completed by WGBH staff

Date received:

Student ID#

3/8/01