Student: ______________________________________ Date of Birth: ________________
| Grade | 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 |
| 0-10 | 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 | |