Name
O&M Evaluation (Date)
-6-
REGION 10 EDUCATION SERVICE CENTER
Division of Instruction
SUPPLEMENTARY SERVICES FOR VISUALLY IMPAIRED
C O N F I D E N T I A L
STUDENT INFORMATION
Student Name: D.O.B: Age:
District: Campus: Placement/Grade:
Date of Evaluation:
Evaluation Environments: (Include familiar/unfamiliar; indoor/outdoor; day/night; school, day care, home, mall, business, residential, semi-residential, rural; etc. See O&M Suggestions)
Conducted by: , Certified Orientation and Mobility Specialist
Purpose:
· To determine eligibility and level of service for Orientation and Mobility services
· ARD requested
· Three year re-eval
Observations: (see O&M Suggestions)
VISUAL/MEDICAL INFORMATION
(Visual and additional disability information should be obtained from the FVE/LMA, FIE, or eye doctors report- See O&M Suggestions)
Eye doctor:
Date of eye exam:
Visual diagnosis:
Age of onset:
Prognosis:
Doctor Recommendations:
Visual prescriptions:
Acuity:
Field restrictions:
Light sensitivity:
Color discrimination:
Hearing:
Additional disabilities/other medical information: (See O&M Suggestions)
ADDITIONAL INFORMATION
Sensory Modality: (Ex: tactual, olfactory, visual, auditory, etc) (See O&M Suggestions)
Literacy medium/media used: (Ex: Braille, large print, regular print, auditory instruction, object symbols, etc) (See O&M Suggestions)
(All following (*) headings are not applicable for infants)
*Optical devices used: (See O&M Suggestions)
*Student interview summary: (see TAPS Evaluation booklet)
Parent/guardian interview summary: (see TAPS Evaluation booklet)
School personnel/ECI summaries: (see TAPS Evaluation booklet)
Previous O&M instruction received: (See O&M Suggestions)
PROCEDURES AND EVALUATION RESULTS
Evaluation tools/methods used:
· TAPS
· Oregon Project
· INSITE
· Inventory of Purposeful Movement
· Region10 Low Vision Evaluation
· Region 10 Concept Assessment
· Informal Observation
· Indoor Assessment Form
· Map Assessment Form
· Residential Assessment Form
· Small Business Assessment form
· O&M Screening
· Teacher Interview
· Student Interview
· Parent Interview
· Other
Attending Behaviors: (Ex: tactual defensive, timid, outgoing, specific mannerisms, behavior plan, etc. See O&M Suggestions)
(*Infants only- from this point on, you may report your findings for infant evaluation using the format below, or you may report the findings according to the outline of your assessment tool- see Infant Suggestions)
Expressive and Receptive Language Skills: (Ex: calendar systems, routines, electronic talking device, object symbols, typical communications skills, pre-verbal infant, 10 word vocabulary, gestures, sign, etc) (See O&M Suggestions)
Motor Skills/posture & gait/physical endurance: (Ex: reaching, rolling, scooting, crawling, cruising, walking, non-mobile, etc) (See O&M Suggestions)
Use of low vision: (Ex: field loss, distance vision, scanning & tracking, auditory/visual localizing, etc) (See O&M Suggestions)
Use of low vision devices: (Ex: monocular, magnifier, CCTV, etc) (See O&M Suggestions)
Use of mobility devices: (Ex: cane, wheelchair, gait trainer, pre-cane, adaptive cane, etc) (See O&M Suggestions)
Body imagery & Spatial awareness: (Ex: body parts, social positioning of body, awareness of appearance, etc) (See O&M Suggestions)
Concept development: (See O&M Suggestions)
· Directional and positional
· Laterality and directionality
· Quantitative (size, length, weight, etc)
· Color
· Cardinal directions
· Environmental (layout of school, block, etc)
Travel Skills: (See O&M Suggestions)
· Guide technique
· Basic skills (protective techniques, search patterns, etc)
· Cane skills
· Orientation to environment
· Travel within the home environment
· Travel within the school environment
· Travel within the residential environment
· Travel within the commercial environment
o Small business
o Downtown
o Community experiences
· Use of public transportation
· Night travel
· Non-visual travel (use of occluders)
· Ability to gather and use information (call DART, utilize internet to access maps, schedules, etc, GPS)
· Ability to problem solve/organizational skills/memory
Expanded Core Curriculum: (See O&M Suggestions)
The Expanded Core Curriculum includes a set of skills that are impacted by vision loss and may require intervention and systematic instruction.
· As part of ongoing informal checklists, information concerning strengths and areas of needs in the Expanded Core Curriculum will be gathered for (Student), and IEP goals will be drafted if need is identified.
· A review of (Student’s) skill level in several Expanded Core Curriculum areas revealed some areas of need. Identified areas included (e.g.: self-determination, social skills and leisure recreation skills, daily living skills, etc). Goals addressing these skills will be drafted.
SUMMARY: (write 1-2 paragraphs on areas of overall strengths and concerns of students orientation and mobility skills)
A. Based on this evaluation, (Student) does not need direct orientation and mobility training at this time to benefit from instruction.
B. Based on this evaluation (Student) needs direct orientation and mobility training to benefit from instruction. It is suggested that the ARD consider direct services
minutes X per week or minutes every 2 4 weeks.
C. (Student) was capable of safe and independent travel in familiar indoor environmental situations and consistently demonstrated appropriate __ independent travel skills OR __ cane skills.
D. However in a more complex situation, additional direct orientation and mobility instruction will be required. Continued direct orientation and mobility instruction will enable (Student) to travel with confidence in a greater variety of travel situations.
E. Current appraisal indicated that (Student)’s present needs can be met most appropriately through consultative assistance designed to monitor maintenance of skills and level of independence previously attained. It is suggested that the ARD consider consultative services ___ minutes ___ x per week or ___ minutes every 2 4 6 9 ___ weeks.
F. (Student) was capable of safe and independent travel in ___ familiar indoor environments ___ various indoor environments ___ a variety of environmental situations.
G. Realistic appraisal of current educational program, academic schedule, and commitments, indicated that off-campus instructional objectives can be addressed most appropriately during the summer months. Therefore, it is recommended that (Student)’s present need be met through consultative assistance designed to monitor maintenance of the skills and level of independence previously attained, and that he/she receive direct orientation and mobility instruction during the summer months. It is suggested that the ARD consider direct O&M services ___ sessions for ___ minutes during the summer months.
H. In conclusion, it is recommended that (Student) continue to travel under supervision in unfamiliar or potentially dangerous situations when traveling off campus. Consultative assistance will be provided in order to monitor the student's independent travel skills. An appropriate sighted guide technique is recommended and, as (Student)’s experiences in off-campus travel increase, it is anticipated that he/she will be capable of supervised travel in a variety of community areas.
I. However, in more complex travel situations (traffic-light controlled intersections, right turn lanes, business areas, parking lots, etc.) additional direct orientation and mobility instruction will enable the student to travel with confidence in a greater variety of travel situations.
According to the guidelines established by the Individual with Disabilities Act and the Commissioner/SBOE rules (Student) needs O&M services to benefit from instruction. This service needs to be delivered in the school, home, and/or community to address these (this) training need(s):
1. Spatial and environmental concepts and use of information received by the senses to establish, maintain, or regain orientation and line of travel.
2. To use the long cane to supplement visual travel skills or as a tool for safely negotiating the environment.
3. To understand and use remaining vision and low vision devices
4. To learn concepts, techniques and tools needed for safe independent travel.
5. Other:
RECOMMENDATIONS:
1. Orientation and mobility consultation is recommended minutes X per week or minutes every 2 4 6 9 weeks.
2. Direct orientation and mobility instruction is recommended minutes X per week or minutes every 2 4 weeks.
3. Continued direct orientation and mobility instruction is recommended minutes X per week or minutes every 2 4 weeks.
4. Discontinue direct orientation and mobility training.
5. Orientation and mobility services are not recommended.
6. An Orientation and Mobility Specialist will attend the ARD upon request.
7. The physical education teacher needs to be aware of (Student)’s limited eyesight.
8. Contact Region 10 if any questions or problems involving travel occur.
9. Re-evaluation is available upon request as (Student) matures and/or needs or environment change.
10. Refer for OT/PT evaluation.
11. The student needs to be provided with opportunities to travel independently within the
school in order to practice and maintain good orientation and mobility skills.
12. Encourage use of Low Vision Aid. Provided the student continues to demonstrate the appropriate use of the monocular aid, as was evidenced during this period of evaluation, (Student) is capable of a greater degree of independent travel. It is recommended that he/she be encouraged to use the monocular aid in a variety of environmental situations.
13. (Student) should apply mastered cane skills when traveling in the school environment.
14. (Student) should apply an appropriate sighted guide technique when physical assistance is required.
15. The student should be supervised when traveling to and from classes, within the school environment, in unfamiliar off-campus situations.
16. Summer orientation and mobility instruction is recommended for __ sessions in June, __ sessions in July and/or __ sessions in August (prior to school starting).
17. Other:
Signature of Evaluator
Certified Orientation and Mobility Specialist
Education Service Center, Region 10
Position/Agency
It is the policy of Region 10 Education Service Center not to discriminate on the basis of race, color, national origin, gender or handicap in its vocational programs, services or activities as required by Title VI of the Civil Rights Act of 1964, as amended; Title IX of the Education Amendments of 1972; and Section 503 and 504 of the Rehabilitation Act of 1973, as amended. Region 10 Education Service Center will take steps to ensure that lack of English language skills will not be a barrier to admission and participation in all educational programs and services.
THIS INFORMATION TO BE USED WITH PROFESSIONAL STAFF ONLY IN KEEPING WITH FERPA & IDEA CONFIDENTIALITY REQUIREMENTS. 8/12