FBC Vision Screening Template (FVA LMA)

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FUNCTIONAL VISION ASSESSMENT AND

LEARNING MEDIA ASSESSMENT

Student: NAME    


DOB:
School District:
School Placement:
Eye Condition:
Evaluator(s):
Date(s) of Assessment:
Date of Report:

PURPOSE: This Functional Visual Assessment (FVA) was conducted to provide current information
about how effectively STUDENT utilizes her vision, the extent to which reduced visual functioning
affects their educational program and specific needs for modification related to their visual impairment.
STUDENT is in GRADE and experiences some issues with identifying colors and faces and this
assessment will help the team create an appropriate education plan with recommendations to inform
the multidisciplinary team evaluating their strengths and areas of need for special education.

Functional Vision Assessment (FVA): is an organized plan for observing how a student uses their vision
to perform routine tasks and to what extent this impacts learning and performance. The assessment is
performed using tests to determine the student’s color vision, contrast sensitivity, lighting preferences,
depth perception, tracking abilities, shift of gaze ability, scanning ability, eye preference, and
convergence ability. The Logarithmic Near Visual Acuity Chart and The Original Distance Test Chart for
Partially Sighted used to determine the student’s visual acuity. In STUDENT’s case this Functional
Vision Assessment (FVA) is conducted in order to provide current information on STUDENT’s
functional vision status specific to CVI, and to provide concrete recommendations for her educational
program and functional skills development.

ASSESSMENT STRATEGIES
 Review of previous and current records (eye reports)
 Informal assessment of functional vision use
 Interviews with the student’s parent
 Observation of the student in A SCHOOL
 Direct assessment of reading and writing skills

OCULAR HISTORY:  

INFORMAL OBSERVATION:

RESULTS OF FUNCTIONAL VISION ASSESSMENT


Setting: The evaluation took place at 2:00pm in an educational room at Foundation for Blind Children.
The room had fluorescent and natural sun lighting. STUDENT wore her prescription glasses during the
assessment.

Oculomotor Functions
 Appearance of the eyes:
o Check students eyes, look for goop, color, or any abnormalities in eyes.
 Blink Reflexes:
o Ask student a question (Can you tell me who your favorite Disney character is
and what you like about them?)

 Alignment:
o Hold an object in front of student’s eyes at certain distances away and check to
see if their eyes are properly aligned. Patch each eye and repeat holding object
at distances checking for alignment.

 Pupillary Reflexes:
o Turn lights off in room. Use pen light to check for pupillary responsiveness from
peripherals toward the pupil.

 Head Movements:
o Have student follow finger puppet in different directions to track head
movements.

 Convergence/Divergence:
o Have student read what is on the whiteboard, and then have them read the word
that is down on their paper to see if their eyes convergence, and vice versa for
divergence.
o Check with using finger puppet to bring it in closer to converge and see if eyes
turn inwards to adjust. Check pulling puppet away to see if eyes diverge and
eyes turn back outward.

 Fixation:
o Use finger puppet and see if student stays fixated on object. Try at different
distances.

 Shift of gaze:
o Hold out two objects on either side of the student’s face, and tell student to look
at one and then the other.

 Tracking:
o Hold finger puppet in front of student’s face, tell student to track the puppet and follow it
with their eyes while not turning their head. Move puppet to the left to right, up and down
and see if student is tracking.

 Scanning:
o Use iSpy book and tell student to look for an object, and then another, check
eyes to make sure they are scanning. Tell student to look for a wall clock. Using
Bananagrams letters, have student find the letters to their name or other words.

 Eye preference:
o Use paper towel telescope and tell the student to look for the clock on the wall.
Observe which eye they bring the roll up to.

 Visual motor behavior:


o Have student stand up, and try throwing a ball to her to see if she will catch it.
Check to see how student is using their hands to catch, and are they keeping
their eyes on the ball?

 Peripheral Visual Fields: An informal confrontation field test was used to assess STUDENT’s
peripheral visual field. The test suggested a visual field loss. A full visual field generally extends
90° to the left and right, 45° above, and 65° below midline. The diagram below illustrates normal
visual fields. STUDENT was observed to recognize an object that was presented in her
peripheral field from all sides within 75 – 90° on their left and right sides. He was able to
recognize an object at 45° from the top and bottom.

Functional Acuities, Depth, Contrast, and Color Perception


 Near Vision (activities that occur within arm’s reach):
o Formal Near Visual Acuity: STUDENT’s formal near visual acuity was assessed using
The Logarithmic Near Visual Acuity Chart with correction.
OU (both eyes): 20/
o Functional Visual Acuity: STUDENT was observed to hold objects at a normal distance
for viewing.

 Distance Vision (activities that occur beyond 6 feet):


o Formal Distance Vision Acuity: STUDENT’s distance visual acuity was assessed using
The Original Distance Test Chart for Partially Sighted by William Feinbloom with
correction.
OU (both eyes): 20/
o Functional Visual Acuity: STUDENT demonstrated that he had more difficulties seeing
objects that were farther away.

 Depth Perception
o Check how student does on stairs.
o Have student collect a set of 3-D colorful puff balls on a flat 1-D dotted colorful
background.

 Color Vision:
o Using small colorful puff balls, see if student can identify the different colors and sort
them together.

 Contrast Sensitivity:
o Use contrast letters and symbols from binder.

 Light Sensitivity and Light Dark Adaptation:


o Check if student is squinting in bright light areas. Take student outside. Ask student if
the lighting is comfortable for them. Check body language. Ask them to look up towards
the overhead light and check sensitivity. Have student read words on a whiteboard when
the lights are dimmed, or off, and then when the lights are bright.

RESULTS OF LEARNING MEDIA ASSESSMENT


Setting: The evaluation took place at 2:00pm in an educational room at Foundation for Blind Children.
The room had fluorescent and natural sun lighting. STUDENT wore her prescription glasses during the
assessment.

Use of Sensory Channels:


 Auditory:
 Visual:
 Tactile:

Writing Inventory
 Use of technology for writing?
 Draw shapes with a pen or pencil?
 Write her name or a sentence on regular paper, then bold lined paper
 Have student practice copying a passage on to bold lined paper. See how fast student
can write in a minute.
 Have student take a typing test online on an iPad or computer. See how fast they can
type.

Reading Inventory:
 Does STUDENT have any large print books at home?
 What grade reading level is she reading at?
 Is she having trouble going from left to right, top to bottom?
 Have student read half of a grade level passage, and see how many words per minute
she reads.
 Have student practice using a CCTV to read the passage, and see how she does.
 Using The Logarithmic Near Visual Acuity Chart with correction, STUDENT was able to
depict letters at letter size __________________, indicating that he will need print
materials to be at least ___________ point font for near viewing activities.

This is size 25 point font.


Initial Selection of Literacy Medium:
 Since STUDENT primary sensory channel is ------------, she should have ______________ given
to her in ______________. STUDENT will benefit from auditory instruction and explanation.
Additionally, the use of tactile manipulatives will also help STUDENT development of other
concepts.

SUMMARY OF ASSESSMENTS:
STUDENT has received an assessment from an Orientation and Mobility Specialist for services
regarding enhancement of body awareness, object permanence, spatial recognition, the use of
exploring/trailing techniques, and emphasis in following directions to prepare her for being a safe and
independent traveler in her life.

ELIGIBILITY OF VISION SERVIVCES:


(As required under IDEA and A.R.S. 15-766)

Based on the review data, evaluation results and consideration of all areas of suspected disability,
STUDENT is determined to be eligible for special education services pursuant to current state and
federal (IDEA, A.R.S. 15-766) guidelines and statutes. She has been found to be a student with a
Vision Impairment, that even with correction, adversely affects performance in the educational
environment. This visual impairment has been verified by an ophthalmologist, and does require special
education services in order for her to receive a free and appropriate public education. All areas of
suspected disability were considered and the above eligibility will be agreed to by STUDENT ’s
multidisciplinary evaluation team. STUDENT will need vision services to be provided by a Certified
Teacher of the Visually Impaired (CTVI).

ADAPTATIONS:
It will be important to make sure that STUDENT has preferential seating, and is placed closest to the
teacher or board when there is an activity that requires viewing. STUDENT should have access to large
print materials for activities or large print books to follow along in for stories. She should also be seated
under well-lit fluorescent lighting.

FURTHER EVALUATIONS:
STUDENT should continue to receive regular vision examinations with their ophthalmologist.
STUDENT should have a visit scheduled at the Foundation for Blind Children with the Low Vision
Specialist, Dr. Lisa Chiles to perform a Low Vision Evaluation. This assessment is not intended to
replace the formal visual evaluation conducted by an eye doctor. This assessment conveys information
about how STUDENT uses their vision in the classroom environment.

RECOMMENDATIONS
1. Based on STUDENT vision diagnosis and functional vision assessment, he qualifies as
a student with a visual impairment and meets the Federal IDEA definition of visual
impairment impacting educational access. He would benefit the services of a Certified
Teacher of the Visually Impaired Students (cTVI).
2. STUDENT would benefit from an evaluation with a Certified Orientation and Mobility
Specialist (COMS) in the near future for services regarding enhancement of body
awareness, object permanence, spatial recognition, the use of exploring/trailing
techniques, and emphasis in following directions to prepare him for being a safe and
independent traveler in their life.
3. STUDENT should be scheduled in kindergarten for a Low Vision Evaluation with Dr. Lisa
Chiles at Foundation for Blind Children to evaluate their vision and need for devices.
4. Provide STUDENT with large print materials for near viewing, and provide him materials
in front of him that are presented at a distance.
5. STUDENT should be seated closest to activities being presented, and allow him to move
closer for best viewing of lessons, board work, etc.
6. Any print material should be enlarged to at least 25 point font.
7. Although STUDENT is a visual learner, it will be beneficial for him to learn about
concepts through tactile and auditory exploration.
8. Incorporate opportunities to play using all of the senses of sight, touch, taste, smell, and
auditory information.
9. Give STUDENT preferences to work under certain fluorescent lighting conditions. He is
sensitive to too much light and has difficulties in dimmed lighting.
10. Encourage STUDENT to wear sunglasses when he is playing outside due to their
sensitivity to light.
11. Encourage STUDENT to use self-advocacy as a way of communicating their needs with
lighting, print size, or eye fatigue when working.
12. Although STUDENT reads large print, introduction to braille skills will be helpful to
STUDENT if their vision loss progresses and their need for braille increases.
13. Participation with Foundation for Blind Children’s SHARP program for sports,
habilitation, art, and recreation with visually impaired peers.
14. According to The Michigan Vision Services Severity Rating Scale (July, 2017), it is
recommended that STUDENT receives 60 minutes a week for vision services with a
certified teacher of visually impaired students to introduce braille skills, technology skills,
and self-advocacy skills.

REFERENCES

It was a pleasure working with STUDENT and their parents. If any member of STUDENT family
or the Multidisciplinary Team has any questions or comments about the contents of this report,
please feel free to contact the Foundation for Blind Children at (602) 331-1470. I can be
reached at (123) 456-7890, or by email at [email protected] .

YOUR NAME, BS Ed., cTVI


Certified Teacher of the Visually Impaired
FOUNDATION FOR BLIND CHILDREN
1234 East Northern Avenue | Phoenix, AZ 85020

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