Functional Vision Assessment
Students with Cortical Vision Impairments
Student Name: Report Date: Examiner:
Assessment Instrument: Assessment Dates:
Reason for Assessment:
Background Information
Setting for Assessment/Program
Previous and Current Vision Services
Other Medical History
Visual History
Appearance of the Eyes
Interviews (collect information from various perspectives across multiple settings and activities)
Teacher Interview Summary and Date:
Parent Interview Summary and date:
Observations ((indicates areas of strength and need related to vision in each of these areas)
Classroom
Recess
Lunch
Orientation and Mobility Observation/Screening/Evaluation
Other
Cortical Vision Scale
Color Preference: Most children who have CVI respond more quickly to objects of a particular color.
Need for Movement: Many children with CVI respond best visually to targets that move in space or that have reflective surfaces.
Visual Latency: The characteristic of visual latency is one in which there is a delayed response between the time a target is presented and the time the individual first notices it.
Visual Field Preferences: Many children with CVI have strong visual field preferences.
Difficulties with Visual Complexity: Difficulties with visual complexity can mean difficulty with complexity of the surface of an object, of the viewing array, or of the sensory environment.
Light-gazing and Nonpurposeful Gaze: Some children with CVI spend prolonged periods of time gazing at primary source of light.
Difficulty with Distance Viewing: Some students with CVI have difficulty with distance viewing as though they were highly nearsighted.
Atypical Visual Reflexes: there are two responses whose lack is often associated with CVI. The blink reflex is one in which the individual blinks simultaneously to a touch at the bridge of the nose. The second reflex occurs when an individual blinks as a target (usually an open hand) moves quickly toward the face at midline.
Difficulty with Visual Novelty: Many children with CVI tend to visually attend to objects or targets seen previously, but may ignore visually novel or new things.
Absence in Visually Guided Reach: Some children with CVI do not display the ability to look at and touch an object at the same time as the actions are performed separately.
Summary
Based on the CVI Range Assessment, (student’s name) scored in the (range score).
This means
Recommendations
Used by permission Christine Roman-Lantzy AFB Press, 2007
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