Sample Forms
Below are descriptions of 5 students.
Download the student description and the associated O&M VISSIT form
- Sample O&M VISSIT – STUDENT A “Amber”
- Sample O&M VISSIT – STUDENT B “Brandon”
- Sample O&M VISSIT – STUDENT C “Caleb”
- Sample O&M VISSIT – STUDENT D “Deana”
- Sample O&M VISSIT – STUDENT E “Ella”
Sample O&M VISSIT – STUDENT A “Amber”
Amber is a 16-year-old student who has a history of multiple severe, and profound health impairments including intellectual disability, cerebral palsy, seizures, and “likely cortical vision impairment.” She is considered legally blind and, according to doctor reports, “appears to have no vision.” Amber receives services in a self-contained classroom with two nurses on staff. Amber does not demonstrate independent movement or mobility but does exhibit limited movement with her arms and feet. She is able to alert to sounds and to her name being called; turn or tilt her head towards music, bells, and instruments; sit in an adapted chair; smile when she is happy. Amber has been receiving O&M services for several years. Her primary areas of need are body awareness, movement activities, and familiarization to campus (being moved about in her wheelchair while environmental features are narrated by the staff member). She also needs to work on directional and positional concepts and increased use of her auditory and tactile senses. Amber’s parents have asked for additional support in knowing how they can best provide consistency in routines and increase her orientation in the home environment.
Amber can attend to and occasionally track sound sources and familiar voices. She occasionally attends to other targets that are either lighted or have reflective qualities (e.g., shiny chains of beads suspended on frame), but this is not a definitive indication of vision. No distance viewing is observed. Results from her learning media assessment indicate that Amber relies heavily on her auditory mode for learning, but due to one of her diagnosed syndromes, she has been counted as Deafblind for purposes of the Deafblind census.
Sample O&M VISSIT – STUDENT B “Brandon”
Brandon is a 10-year old 4th grader in a general education classroom with paraeducator support and reading remediation class. He is diagnosed with optic atrophy, with an estimated acuity of 20/900 and severe peripheral vision loss. Brandon receives support throughout his day from the one-on-one aide, TSVI, and O&M specialist. He is functioning below grade level in all areas of the core curriculum, as he only began receiving visual impairment services two years ago and missed crucial learning in the early years and grades. Brandon is an emergent braille reader, learning to read while learning braille simultaneously. Brandon has a cane, but does not recognize or acknowledge his need for a cane because he is comfortable and somewhat successful in navigating his familiar home and some campus environments (due to memorization). He is overconfident in his travel and has frequent accidents due to his risk-taking behavior. Learning non-visual strategies to use for orientation and mobility purposes would increase his safety and independence.
In addition to O&M, literacy needs, assistive technology, and access to the core curriculum, an ECC evaluation conducted last semester indicated significant needs in the areas of organizational skills, communication modes, social interactions, personal care, and self-determination.
Sample O&M VISSIT – STUDENT C “Caleb”
Caleb is a 2-year old student with Down syndrome and low vision. He has been receiving services through ECI for OT, PT, Speech, VI, and O&M. He currently wears glasses and has normal hearing. Caleb lives in a home where the primary language is Spanish. Based on information from his current eye report, Caleb’s best corrected visual acuity at near and distance was about 20/100 with no apparent visual field restriction. He seems to function within the 20/80-20/100 range. According to the results of the Oregon Project Curriculum and Skills Inventory, Caleb is functioning below age level in the areas of cognitive development, compensatory skills, social skills, language, fine motor, and gross motor. Caleb’s greatest areas of need are language development and self-help skills.
Caleb receives services in the home due to his young age, but has three older sisters, all in middle school or high school. Caleb is just beginning to model after his older siblings. His strengths include exploration within familiar indoor environments (hindered by low muscle tone) and frequent interactions with family and service providers. His greatest area of need up until the last two months was communication. Though his receptive skills are excellent, his expressive language includes some babbling and attempts at words (nouns). Caleb’s mother is very involved and shows overly cautious behavior at times. She is expressing doubts about allowing Caleb to enter PPCD on his 3rd birthday, preferring to keep “her baby” home.
Sample O&M VISSIT – STUDENT D “Deana”
Deana is a 9th grade student in a rural district who attends some general education and some remedial classes. Her visual diagnosis is congenital glaucoma and cataracts, with an acuity of 20/150 in her left eye, and light perception in the right. Deana is very social and has friends; however, she does encounter bullying. Deana feels this is related to her physical appearance (one eye that is very cloudy and opaque – she wants a colored contact for cosmetic purposes).
According to her Expanded Core Curriculum (ECC) evaluation, Deana’s strengths include social skills, recreation/leisure (she wants to try out for cheerleader), independent living skills, and career education. Her needs in the ECC include the areas of assistive technology (iPad use for access to documents and distance targets), compensatory skills (specifically access to large print and learning to use audio materials to compensate for visual fatigue and taking notes on her iPad), self-advocacy (letting adults know what her visual accommodation needs are), and sensory efficiency (using methods to improve her visual functioning in school and home settings).
Deana reads below grade level and is being evaluated for dyslexia. She prefers not to use large print books or materials and refuses optical devices and a cane for identification or safety purposes. Deana would benefit from activities (which include cane training in new, more complex environments) designed to increase her experiences and prepare for transition.
Sample O&M VISSIT – STUDENT E “Ella”
Ella is a 12th grade student in a large urban school district who attends all general education and advanced (AP /dual credit) classes. Her visual diagnosis is high myopia and cone-rod dystrophy. Her acuity is 20/100 after correction in both eyes, and she has been receiving services from a TSVI since her 10th grade year, after experiencing difficulty accessing educational materials. Ella demonstrates appropriate social interaction skills and has many friends, due to her involvement in various school clubs and activities.
Ella demonstrates adequate travel skills on campus during daytime hours. She is preparing to transition to a large in-state university. She would benefit from introduction to cane travel and adaptations for low vision due to the progressive nature of her diagnosis, but she and her family are concerned about missing academic time to participate in O&M lessons. Her O&M evaluation results indicate a need for skill development for night travel, independent street crossings, public transportation, and use of optical devices.
