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Student: ______________________________________  Date of Birth: ________________

Grade

Teacher of the Visually Impaired

Date Completed
     
     
     

RECOMMENDATIONS OF SERVICE

DATE SEVERITY RATING FREQUENCY MIN/WEEK MODEL OF SERVICE DELIVERY
         
         
         
         

 

SEVERITY SCORE SEVERITY RATING FREQUENCY OR MIN./WEEK MODEL OF SERVICE DELIVERY
0-10 1 1-5/YEARLY MONITORING
11-36 2 1-2/MONTHLY CONSULTATION
37-54 3 1-2/Week or 30-100 MIN. SUPPORTIVE
55-72 4 3-5/WEEK or 60-300 MIN. DIRECT
73-90 5 5+/WEEK or 180-360 MIN. INTENSIVE
90-108 6 5+/WEEK or 240-600 MIN. COMPREHENSIVE

 

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. Student cooperation _____ 11. Other ____________________
            ____________________________
_____ 6. Parent concern