f u n c t i o n a l v i s i o n e v a l u a t i o n a s s e s s m e n t- s f a s u（l f u n c t i o n v i s i o n e l u t i o n s s e m e n t - s f年代u）.docVIP

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f u n c t i o n a l v i s i o n e v a l u a t i o n a s s e s s m e n t- s f a s u（l f u n c t i o n v i s i o n e l u t i o n s s e m e n t - s f年代u）.doc

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______________ INDEPENDENT SCHOOL DISTRICT FUNCTIONAL VISION EVALUATION LEARNING MEDIA ASSESSMENT 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 Commissioners/State Board of Education rules. The students visual impairment adversely affects/does not adversely affect the students educational performance. This student seems to have the necessary visual components to learn from her environment without visual modifications, and does not qualify for VI services. II. PURPOSE OF EVALUATION: This student was referred for an Initial Function al Vision Evaluation and Learning Media Assessment to determine qualification and educational need for services from a teacher of the visually impaired. OR This student was referred for a Functional Vision Re-evaluation and Learning Media Re-assessment to determine qualification and educational need for (continued) services from a teacher of the visually impaired. III. BACKGROUND INFORMATION and MEDICAL HISTORY This student is a year old attending grade at School. The most recent FVE/LMA was dated , and at that time she/he qualified / did not qualify for VI services. She/he has been receiving vision consult/ direct services for the school year . Attached are the VI goals and objectives written at the last ARD dated, showing level of mastery attained. This student was most recently seen by Dr. in on . The eye exam report indicates that this student has a diagnosis of , with the etiology of , and the prognosis is . The visual acuity was measured at 20/ near and 20/ distance, with best correction, and with both eyes together (if there is only info about each eye separately, state each of those visual acuities). There is no/an apparent field loss, col