______INDEPENDENT SCHOOL DISTRICT
FUNCTIONAL VISION EVALUATION
LEARNING MEDIA ASSESSMENT
NOTE: make appropriate choices from highlighted areas; delete this note and any examples or explanations in parentheses.
Student Name: Date(s) of Evaluation:
DOB: Evaluator:
Campus: Title:
I. ELIGIBILITY STATEMENT
Based on the most current report from an eye specialist and the results of the Functional Vision Evaluation, this student (appears/does not appear) to meet eligibility as visually impaired as defined by the Commissioner's/State Board of Education rules. The student's visual impairment adversely affects/does not adversely affect his/her educational performance.
II. PURPOSE OF EVALUATION (ex: New referral, 3-year reevaluation, change in visual functioning, etc.)
III. BACKGROUND INFORMATION (ex: grade and placement, school attendance, family background, past VI/O&M qualification & services, past evaluations, interviews, etc.)
IV. MEDICAL HISTORY
A. (Last eye report – who, where, when, diagnosis, results, prognosis, recommendations. Remember to define eye conditions and their implications.)
B. (Any other medical conditions)
V. FUNCTIONAL VISION EVALUATION
A. Sources of Data
B. Environments
C. Physical/Optical Findings
D. Near Vision
E. Mid-Range Vision
F. Distance Vision
G. General Mobility
VI. LEARNING MEDIA ASSESSMENT
A. Primary & Secondary Sensory Channel
B. Learning Medium
C. Literacy Medium
D. Based on the Functional Vision Evaluation and Learning Media Assessment, student behaviors, teacher/parent/student interviews, and eye doctor’s report, this student is/is not functionally blind. The student will/will not need Braille instruction or materials at this time.
VII. EDUCATIONAL IMPLICATIONS (Because of the eye condition, what are some of the visual problems that the student may encounter within the learning environment? What will the teachers need to be made aware of? What may need to be changed in the environment?)
VIII. RECOMMENDATIONS
A. (Readdress eligibility.)
B. (Address the need for a “clinical low vision evaluation”, and if not needed, state why.)
C. (Address the need for an orientation & mobility evaluation, and if not needed, state why.)
D. (VI services to address what? Direct? Consult? How often? For how long each time?)
E. (Address what modifications need to be made in the FIE/state testing)
IX. All other recommendations including, but not limited to:
A. learning media
B. modifications to the environment
C. supplemental aids and equipment
D. adaptive technology
E. teaching strategies
F. physical education
G. vision related services
H. evaluation and testing strategies
I. areas of needed instruction in compensatory skill areas
(Add an ending statement here.)
______
(Evaluator’s name, letters of title)
(Title in words)
FVE/LMA Student: Date: 2
: