Student: ______________________________________ Date of Birth: ________________
| Educational Setting | Teacher of the Visually Impaired |
Date Completed |
|---|---|---|
| DATE | SEVERITY RATING | FREQUENCY | MIN/WEEK | MODEL OF SERVICE DELIVERY |
|---|---|---|---|---|
| SEVERITY SCORE | SEVERITY RATING | FREQUENCY OR MIN./WEEK | MODEL OF SERVICE DELIVERY |
|---|---|---|---|
| 0-20 | 1 | 1-5/YEARLY | MONITORING |
| 21-36 | 2 | MONTHLY OR BI-MONTHLY | CONSULTATION |
| 37-46 | 3 | 2-4/MONTHLY | INTERMITTENT DIRECT |
| 47-56 | 4 | 90-240 MIN/WEEKLY | DIRECT |
PROFESSIONAL JUDGMENT FACTORS: |
|
|---|---|
| _____ 1. Age of student | _____ 7. Attendance |
| _____ 2. Availability of materials/equipment | _____ 8. Progressive condition |
| _____ 3. Classroom teacher's need for support | _____ 9. Home environment |
| _____ 4. Transition to a new school/building | _____ 10. Visual field restriction |
| _____ 5. Additional support provided | _____ 11. Other ____________________ ____________________________ |
| _____ 6. Parent concern | |