VISION SEVERITY CHARACTERISTICS WORKSHEET FOR STUDENTS WITH ADDITIONAL IMPAIRMENTS

Student: ___________________________________ School: __________________________

Visual Diagnosis: ___________________________________ Date: ____________________

Teacher of the VI: ____________________________________________________________

Category 0-2
Mild
Visual Needs		 3-4 
Moderate Visual Needs		 5-6
Severe Visual Needs		 7-8
Profound Visual Needs 		 Severity
Score
Date|Date|Date
1. Visual Status  No medically identified vision problem, but ability to attend to visual stimuli is questionable Medically identified vision problem, with ability to attend to visual stimuli Medically identified vision problem, with impaired ability to attend to visual stimuli Medically identified vision problem resulting in profound loss of vision      
2. Functional Visual Status Visual skills being maintained/reinforced in a variety of settings New visual skills being introduced or developed Visual skills fluctuate depending on activity Totally blind-no input      
3. Response to Stimulation/ Instruction Minimal response to stimulation/ instruction Occasional response to stimulation/ instruction Frequent response to stimulation/ instruction Consistent response to stimulation/ instruction      
4. Educational Need Classroom participation is not affected by vision loss Classroom participation is occasionally affected by vision loss Classroom participation is frequently affected by vision loss Classroom participation is consistently affected by vision loss      
5. Educational Growth No measurable gains even after intervention Minimal growth even after intervention Demonstrating growth but on a plateau Continues to demonstrate steady growth      
6. Potential for Improved Use of Vision Minimal, gains appear remote Currently functioning at a level equal to developmental ability Some improvement appears possible, gains probable with vision services Prognosis for improved visual functioning appears to be good      
7. Physical Independence Dependent on special care for medical and daily living functions Dependent on others for daily living functions Dependent on a modified environment, difficulty with certain activities Basically independent      
  TOTAL SCORE