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**Direct Service**
CATEGORY	LOW NEEDS - 1	AVERAGE NEEDS - 3	HIGH NEEDS - 5	SCORE
VISION	No "severe vision loss" noted on eye report, but ability to attend to visual stimuli is questionable Uses vision very well in a variety of settings Very sure of functional vision Visual diagnosis made over 1 year ago Vision is not expected to change in the next 6 months	Able to attend to visual stimuli New visual skills being developed Visual diagnosis made 1 year ago	Unsure of functional vision Difficulty attending to visual stimuli Vision fluctuates Severe vision loss or totally blind Prognosis for improved visual functioning appears to be good (CVI, ROP) Progressive loss of vision expected in next 6 months Visual diagnosis made less than 1 year ago	DIRECT SCORE
HEALTH	Very Medically Fragile No health concerns	Some health concerns (nutrition, etc.)	Chronic ear infections Very premature/low birth weight Significant time spent in hospital	DIRECT SCORE
OTHER IMPAIRMENTS	No additional impairment	Additional impairment	Two or more additional impairments	DIRECT SCORE
DEVELOPMENTAL	No developmental delays	Very slight developmental delays	Vision loss may be contributing to developmental delays Modifications needed	DIRECT SCORE
FAMILY MEMBERS/PRIMARY CAREGIVER	Does not want additional professionals making weekly home visits Understands about their child's vision Distressed about issues other than this child (Financial, Marital, etc.) Does not readily participate in parent child trng.	Needs help learning about the educational systems Want additional resource info Need information about getting the most out of ophthalmological appointments and interpreting reports	Has lots of vision related concerns Needs lots of info about their child's vision Needs additional support Grief issues about vision Needs help bonding with child Needs help reading child's communicative cues	DIRECT SCORE

**Consulting Service**
CATEGORY	LOW NEEDS - 1	AVERAGE NEEDS - 3	HIGH NEEDS - 5	SCORE
PROFESSIONALS ON TEAM	All have experience working with babies with similar vision No questions about ECI or ISD procedures	Few questions about ECI or ISD procedures Few questions about assessment, stategies, etc.	Have no experience working with child with visual impairment Need training in implications, modifications, strategies, communicative cues, etc. for child with VI	CONSULT SCORE
VI TEACHER (Activities in Support of Instruction)	Has significant experience working with babies, babies with visual impairments, and babies with multiple impairments	Has moderate experience working with babies, babies with visual impairments, and babies with multiple impairments	Has little or no experience with babies Needs time to learn from other professionals on team (Motor, Handling, Communication, Infant Development, Working with Families, etc.) Suspected or diagnosed auditory impairment	ACTIVITIES IN SUPPORT OF INSTRUCTION SCORE
OTHER			Child actively explores environment Needs adaptations to learn basic concepts Needs help to generalize skills Needs more exposure to concrete experiences to develop language skills Body imaging, spatial awareness	DIRECT OR CONSULT SCORE
*PROFESSIONAL JUDGEMENT FACTORS (POSITIVE OR NEGATIVE)				DIRECT OR CONSULT SCORE
TOTAL SCORES	DIRECT SCORE	CONSULTING SCORE	ACTIVITIES IN SUPPORT OF INSTRUCTION SCORE

*PROFESSIONAL JUDGEMENT FACTORS:

(THESE CAN BE POSITIVE OR NEGATIVE)

SCORE	FACTORS	BRIEF DESCRIPTION
	Age of Student
	Transition Issues
	Parent Concern/Issues
	Attendance
	Home Environment
	VI Teacher Issues
	Other Professional's Issues
	Child Issues
	Other
	TOTAL

DIRECT SCORE	FREQUENCY AND AMOUNT: DIRECT SERVICES	CONSULTING SCORE	FREQUENCY AND AMOUNT: CONSULTING SERVICES	ESTIMATED TIME FOR ACTIVITIES IN SUPPORT OF INSTUCTION
1-5	2 HOURS PER MONTH	1-2	2 HOURS PER MONTH	PLANNING
6-20	1 HOUR PER WEEK OR 2 30 MIN. SESSIONS/WEEK	3-4	1 HOUR PER WEEK	PREP
21-25	2 HOURS PER WEEK	5-9	2 HOURS PER WEEK	LIAISON
26-30	3 HOURS PER WEEK	10+	3 HOURS PER WEEK	EVALUATIONS
30+	3+ HOURS PER WEEK			IFSP
				MEETINGS
				OTHER

____ DIRECT SERVICE TIME

____ CONSULTING TIME

____ TRAVEL TIME

____ ACTIVITIES IN SUPPORT OF INSTRUCTION

____ TOTAL NUMBER OF HOURS

Teacher of the Visually Impaired

NOTE: To be used with: "GUIDELINES FOR AMOUNT OF SERVICE TO STUDENTS WITH VISUAL IMPAIRMENTS: SAMPLE" (Developed by the VI staff of Denton ISD, Revised by D. Leff and O.F. Morris), Found on pages B-57-58 of the Quality Programs For Students With Visual Impairments Manual

Adapted by Stacy Shafer from:

Michigan's Vision Severity Rating Scale
1996
Printed by the Office of Special Education Services, Michigan Department of Education

Texas School for the Blind and Visually Impaired

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Determining Type and Amount of Services For Infants

Download form in RTF (75k)