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Student: ______________________________________  Date of Birth: ________________

Educational Setting

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
0-20 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

Return to Michigan's Vision Severity Rating Scales List 1996 - 2008