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VISSIT – Sample Completed Forms

Completed forms to show examples and guide TVIs to complete the VISSIT.

Sample Forms


Below are descriptions of 4 students.

Download the Microsoft Word student description and the associated VISSIT form

Sample VISSIT – STUDENT A “Lily”

Lily is a 5-year-old girl who has a history of “extensive multifocal cystic encephalomalacia involving bilateral cerebral hemispheres”. Dr. XXX reports, “likely cortical vision impairment”, legally blind and, “… appears to have no vision”. Lily also has a history of HSV meningitis as an infant, cerebral palsy, seizure disorder, encephalopathy, and developmental delay. 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; and demonstrate discomfort (as when she is wet). She demonstrates the 3 distinct criteria for Cortical Visual Impairment: 1) eye exam does not explain the child’s functional use of vision, 2) history of a neurologic incident or some neurologic sequelae, and 3) demonstrates the unique visual and behavioral characteristics associated with CVI.

With regard to her vision, Lily is able to visually attend to and track an 8-inch lighted red ball when it is presented in either her far left or far right visual field or no more than 12 inches away from her face. She also visually attends to other targets that are either lighted or have reflective qualities. No distance viewing is observed, other than staring at ceiling lights and sunlight for brief moments. Results from her learning media assessment indicate that Lily relies heavily on her auditory mode for learning, but will explore real objects that are of a single, bright color, reflective, and/or can light up.

Lily is transitioning from a school-based self-contained classroom into a homebound setting with services being provided in her home.

Sample VISSIT – STUDENT B “Rose”

Rose is an 8-year old 2nd grader in the resource and general education classroom with inclusion support. Her diagnosis is total blindness due to congenital ocular toxoplasmosis, retinopathy of prematurity, and retinal dysplasia. Rose receives support throughout her day from the resource teacher, TVI, and teaching assistants to address the behavioral needs of her behavioral intervention plan. She is functioning below grade level in all areas of the core curriculum. She is an emergent reader and has mastered the braille alphabet with minimal reversals. Rose is currently reading approximately 15 sight words and is beginning to sound out consonant-vowel-consonant (CVC) words independently. She is reading uncontracted braille at this time. Rose uses a Mountbatten Braille writer and an iPad for music activities during her break time.

In addition to literacy needs, assistive technology, and access to the core curriculum, ECC evaluation conducted 2 months ago indicated significant needs in the areas of organizational skills, communication modes, social interactions, personal care, and self-determination.


Ivy is a 2 year old student with Down syndrome and low vision. She has been receiving services through ECI for OT, PT, Speech, VI, and O&M. She currently wears glasses and has normal hearing. Based on information from her current low vision evaluation, Ivy’s best corrected visual acuity at near and distance was about 20/100 with no apparent visual field restriction. She seems to function within the 20/80-20/100 range. According to the results of the Oregon Project Curriculum and Skills Inventory, Ivy is functioning on age level in the areas of cognitive development, compensatory skills, social skills, fine motor, and gross motor. Ivy’s greatest areas of need are language development and self-help skills.

Ivy is homeschooled with three older sisters, all under 8 years of age. Ivy is able to model after her older siblings. Her strengths include imitation, exploration, highly motivated learning style, and frequent interactions with family and service providers. Her greatest area of need up until the last two months was communication; signing was used which she imitated for her expressive language skills, although her receptive skills are excellent. In the last couple of months she is beginning to try to say the word along with the sign, or at least the beginning sounds of the word. Many excellent APH products, iPad, games, etc., have been used to encourage her communication. Ivy’s family engages all their children in many rich social and independence-building activities, which include peer interactions, field trips, daily routines, and integrating educational activities into daily lifestyle.


Bud is an 8th grade student who attends all general education classes. His visual diagnosis is oculocutaneous albinism, with an acuity of 20/120 in both eyes. Bud is very social and has friends; however, he does encounter bullying. Bud feels this is related to his physical appearance (white hair and very light skin tone). According to his Expanded Core Curriculum (ECC) evaluation, Bud’s strengths include social skills, recreation/leisure, independent living skills, and career education. His needs in the ECC include the areas of assistive technology (iPad use for access to documents and distance targets), compensatory skills (specifically access to small print and learning to use audio materials to compensate for visual fatigue and taking notes on his iPad), self-advocacy (letting adults know what his visual accommodations are), and sensory efficiency (using methods to improve his visual functioning in school and home settings). Whereas Bud reads on grade level, his reading speed is decreased when reading large print books (which he prefers not to use) and homework documents. Bud would benefit from activities (which include optical devices) designed to increase reading speed and fluency so that he will be able to maintain the pace required in his classrooms and access regular print materials more efficiently.

In addition to the needs stated previously, Bud is transitioning into a new high school, and will require orientation to his new campus and support to prepare a portfolio to share with his teachers explaining his etiology and accommodations.