VIEWS: 444 PAGES: 13

NAME:                                         DATE OF BIRTH:
AGE:                     GRADE LEVEL:
                    Certified Orientation and Mobility Specialist
STUDENT NAME was referred to me for an initial orientation and
mobility assessment by his/her team chairperson _________ of
SCHOOL NAME, as part of the (initial eligibility determination process
for Special Education services.) (Individual Educational Plan process.)

Follow up assessments may be necessary to compile any further
available information and to develop appropriate recommendations
based on other specialists’ findings.

INSTRUMENTS FOR EVALUATION: only cite those you used, and
if you used only part versus all of the assessment
Informal Observation
Record Review
Parent Interview
Student Interview
School Team Consult
Teaching Age-Appropriate Purposeful Skills (components)
The Body Image of Blind Children, Cratty and Sams
The Oregon Project (components)
The Hill Test of Selected Positional Concepts

Orientation and mobility describes an individual’s ability to understand his current location, his
chosen destination, as well as how he/she will get to that destination—route, tool or device,
skills, movement and problem-solving strategies required in the process. For the student with
visual impairment or blindness who cannot acquire these skills incidentally through observation of
peers and mentors, these skills must be learned through direct, purposeful and sequential
instruction. For school aged children the Certified Orientation and Mobility Specialist provides this
consistent instruction in the school, home and community settings, as is appropriate to the
student’s age, development, and need.

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net                                1
STUDENT is a _____year old boy/girl who currently attends
___________school and is in the special education classroom of
__________and/or the regular education class of ________. HE/SHE
is mainstreamed for ___________. STUDENT has not received
previously received or been evaluated for Orientation and Mobility
instruction. STUDENT’s current Teacher of Students with Visual
Impairments (TVI) is ____________. STUDENT also receives
additional support services including ____ once weekly and
______twice weekly. STUDENT has developmental disability/cognitive
disability and has a history of documented medical diagnoses.

 STUDENT IS/NOT legally blind and is registered with the
  Massachusetts Commission for the Blind. The certificate is on file
  and his/her social worker is ___________, EMAIL ADDRESS.
 EYE REPORTS STUDENT see ophthalmologist Dr. _____who is
  affiliated with _______hospital. HIS/HER specializes in ______. IN
  HER/HIS report dated _______ Dr. ______cites the following visual
  diagnoses: _______. Dr. _______lists visual acuities of ___right
  eye, _____left eye, ______both eyes viewing. Current visual
  prescription provided is _______________. In this report
  Dr.____recommended a follow-up at ________for
  evaluating__________. Dr. ___ also prescribed additional viewing
  devices: ________. Dr. ____also noted the following which may
  impact STUDENT’s ability to ___________.
 Explain terms, eye conditions, etc., in your own words or use a
  good nontechnical dictionary. Develop “standardized explanations”
  that you develop once, then cut and paste. Use and cite
  references—even if you rephrase.
  (Eye pathology definitions from Dictionary of Eye Terminology,
   Fourth Edition, B. Cassin, 2001.)
 FUNCTIONAL VISION based on above, POSSIBLE resulting
  effects on functional vision include: _________________________.
  (Functional Vision information from Low Vision, 2nd Edition, Nancy
  Levak, Texas School for the Blind, 2001.) Visual acuity references
  the ability of the viewer to identify objects at a given distance
  (numerator—top number) with the same level of detail that a
  person with typical vision would see from a greater distance

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net   2
   (denominator—bottom number). For _________, he “sees” the
   level of detail standing twenty feet from an object that others see
   standing two hundred feet away from the same object. Because
   these acuities are based upon the clinical setting where lighting
   and distractions are controlled, it is best to consider these acuities
   maximal visual function for _____, when the setting and his
   attention are optimized.

Information from reports, including: date; audiologist name and
location of test; impressions; recommendations … State if individual
is verbal/nonverbal, method or mode of communication used,
whether student’s first language is English or state which other
language is first language. Describe if languages other than English
are used in the home. Describe if the student understands spoken
English, or what other alternatives are used to support receptive
skills. If student’s receptive or expressive skills are affected and the
reason is a physical impairment describe that and what equipment is
used (FM system, cochlear implant, secondary to cleft palate,
secondary to cleft palate with repair in January 2001 at age 5, etc.)
If all you have are your own observations and assessment about the
student’s hearing, include observations about if the student can hear
normal conversational levels—in class, hall, busy/louder
environments, near traffic. Describe the student’s ability to track a
sound at, above, below head level, from each direction, locate sound
sources, identify environmental noises, understanding masking
noises, etc. Develop standard phrasing describing the use/need for
audition during travel both now and in the future. Because audition is
often the secondary sense used in making travel decisions in most
environments, ___________’s hearing should be monitored on a
regular basis. __________uses audition to support his/her movement
on the playground to determine when his/her friend has gotten off
the bottom of the slide and it’s _____’s turn to ride. Development of
appropriate auditory skills will support ______’s movement decisions
such as street crossings, and future independent travel within the
school, neighborhood and community.

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List all medical diagnoses, source of information (annual physical or
other) and define diagnoses and outline any particular affects on
O&M skills. Cite references use in definitions of medical conditions.
(Medical definitions from Dictionary of Medical Terms, 3rd Ed., M.
Rothenberg and C. Chapman, 1994.) Unless a diagnosis appears in a
written report--do not include--unless it came directly to you from the
parent in which case include “By report from parent Joe Johnson on
Jan. 1, 2011, Mary Johnson was diagnosed by Dr. Cameron with
attention deficit disorder.” Include new (since last IEP) medical
diagnoses and potential effects on mobility skills. List medications
taken on regular basis, and those taken as needed, and any side
effects on vision, balance, orientation, mobility, etc. Look up side-
effects and cite source. NOTE- if using a www source, include date
information was collected. (Side-effect source: www.pdrhealth.com
on July 5, 2011)
Note any behavioral concerns- self-abusive, PICA, etc.

If available, information from most recent PT report, including date of
report, name of PT, impressions and recommendations. If student
currently undergoing PT evaluation, note that and name of PT.
If no PT reports are available (currently in process and previous PT
report unavailable) comment on observed gait, posture, pace, what
support needed when walking, direction of head when moving. If
using a cane, AMD, walker, wheelchair or combinations—describe
equipment including brand, size, wheels, etc. Describe
environments/situations in which each is used. Comment on need for
consultation with PT for those who are motorically involved if PT not
currently part of team.

No accident or incident reports were available/submitted to this

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net   4
  Dates/times/locations of observations: STUDENT was observed
   over several dates (____) during routine classroom activities at
   ___ time, during physical education class, in transition to lunch in
   the cafeteria, and outside at recess. Overhead fluorescent lighting
   evenly illuminated the classroom and cafeteria with windows
   permitting additional ambient lighting. Hallways someone darker
   with some shadows as every other light was switched off to
   provide energy savings. Lighting was/was not adequate for this
   student’s travel. During physical education class STUDENT played
   _______. Outside on the playground STUDENT chose _______.
  Staff Discussion/Interview: Summarize info from staff including
   concerns for the person in terms of movement safety, inability to
   complete certain tasks, what type of help needed for transitions,
   lunch line, PE, emergency evacuation, safe haven, playground,
   field trips, etc.
  General vision observations: STUDENT walked with his/her head
   up and looking ahead in the direction of travel. HIS/HER pace was
   appropriate and matched his classmates. HIS/HER posture was
   relaxed and HE/SHE moved with confidence, toes directed at ___
   and ___ clock positions. In the lunchroom STUDENT positioned
   HIS/HER face close to the entrees offered as well as the keypad
   when checking out. In the hallway STUDENT usually positioned
   him/her self close to the end of the line for transitions, and tended
   to stay centered in the middle of the hallway.
  Visual acuity: Visual acuities both eyes viewing were measured in
   the classroom and gym and were conducted using the ______for
   standard acuity measurement. STUDENT demonstrated an acuity
   of _______ in these/this setting. In the gym STUDENT was able to
   see and track a COLOR ball, _____inches in diameter from a
   distance of ______. HE/SHE was able to identify a classmate by
   name at _____ distance. STUDENT was able to locate an 4X10
   lighted EXIT sign from a distance of _______. In the classroom
   he/she was unable to locate his/her chair when the lights were
   turned off. STUDENT’S visual function was demonstrably
   decreased during physical education as he/she was distracted and

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net    5
     at times overwhelmed by the sounds and movement students
     around him/her.
    Contrast sensitivity: evaluate in multiple functional settings using
     white, and variations of gray colored objects for collection from
     white background. Use bright colored pieces on bright colored
     backgrounds, cluttered and plain backgrounds.
    Field: confrontational fields when possible, ball games in gym and
    Depth perception: comment on depth perception function seated
     at near and at distance when standing/walking.
    Color vision: evaluate ability to identify/match/label colors and
     usefulness of color vision to identify familiar objects and locations
     a distances 6-8 feet 15+ feet inside and outside
    Lighting needs/glare: comment on light in school and at home
     environment in general, as well as for task specific purposes for
     travel on stairs or areas where elevations change (outside
     walkways around home). Comment also on glare concerns such
     as from exposed bulbs or unshades windows in stairwells, too little
     light in an area
    Sun lens/hat/visor review: If you have the tools include
     assessment of vision / lighting protection needs when outdoors
     and when indoors for comfort if appropriate specifying degree of
     opacity and color of lens. If unable to perform, include general
     recommendations for sun/glare protection at end of report and
     omit this section. If student’s visual diagnosis particularly linked to
     photophobia, indicate that in recommendations.

  Dates/locations/times of observations: and list activities observed
  Staff Discussion/Interview: Summarize info from team and staff
   including concerns for the person in terms of movement safety,
   inability to complete certain tasks, what type of help needed for
   transitions, lunch line, PE, emergency evacuation, safe haven,
   field trips, playground.
  Sighted Guide/Modified Sighted Guide: describe how staff are
   currently assisting individual to walk. Describe how student
   responds to either use of Sighted Guide or a Modified Plan of
   Sighted Guide that you’ve determined works well with the

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net        6
     person. List response to more than one plan for sighted guide if
     needed. For example, two plans might be needed, one for when
     person’s gait is relatively stable and another plan for when the
     person is presenting as unstable and needing more physical
     support when walking.
    Trailing: list observations of person for spontaneous trailing along
     a flat wall surface and along handrails. (If handrails are
     unavailable but the student has the potential to succeed with
     trailing if handrails were installed, then you may need to go to an
     area where handrails are available for assessment purposes and
     then you can make the appropriate recommendations) Include
     observation if student trailing vertical surfaces (bookcases,
    Protective techniques: comment on spontaneous use of standard
     or modified upper and lower protective techniques
    Cane use: assess if this would be appropriate—describe use of
     any anticipator devices.
    Orientation: comment on independent or partial orientation
     ability in familiar settings, including home, school, community.
     Identify sources/strengths of orientation such as physical,
     auditory or other landmarks, time-distance skills, problem solving
     skills. List routes student uses functionally and describe level of
     independence. If student is completely independent for travel
     along a route but requires supervision because he/she cannot
     problem solve then include that information. Note if a person is
     totally dependent on staff or peers for orientation.

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net     7
  ENVIRONMENT: comment on any areas of safety concerns
  Lack of /need for handrails along both sides of stairs, steps,
   drop-offs, ramps. Need for painting contrasting color to that of
   wall. Need for appropriate TYPE of handrail, height and distance
   from wall. Need for handrail to return to ground for cane
   detection. Need for tactile warnings at tops of stairs and on
   landings. Need for marking steps along lips. Describe how the
   stairs should be marked and substantiate why. Provide resources
   for obtaining materials.
  Identify potentially hazardous uneven surface changes and
   propose solutions. Outside the preschool entrance where the
   cement sidewalk abuts the parking lot asphalt, a small heave has
   created a lip of low contrast that presents a tripping hazard for a
   low vision traveler. Please highlight this lip across the width of
   the sidewalk with bright yellow paint.
  Describe lighting needs- along outer walkways, at entrances, in
   hallways, bathrooms, living rooms, dining areas, bedrooms, work
   areas, etc. Focus on obtaining overall indirect wash of light, glare
   reduction, task lighting if needed.
  Need for marking depth perception cues at tops of stairs, steps,
   curbs, areas of buckled or uneven pavement
  Furniture placement for safety and ease of travel, identify use
   and abuse of area rugs, identify protruding objects, describe use
   of various textures to provide orientation cues along surfaces,
   suggest use of “entrance mats” under projecting water fountains,
   suggest boxing in protruding fire extinguishers and electrical
   boxes to the floor, describe providing braille signage where
   useful and appropriate placement of signage, promote use of tall
   step stools enclosed with railings where needed so they are
   detectable with protective techniques and cane techniques

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net   8
  TRANSPORTATION ASSESSMENT: assess ease or safety
   concerns for individual when getting into and out of car, van,
   bus, ability to evacuate bus/van, snap/unsnap seatbelt,
   open/close lock/unlock door, avoid side mirrors on vehicle

   Teaching Age-Appropriate Purposeful Skills (TAPS):
     TAPS is both an assessment and curriculum that identifies concepts and skills utilized by
     persons with visual impairment and blindness for travel. This curriculum is used for
     students aged 3-21 years to focus on skill development in a sequential and functional order
     and to determine areas of need for improved and expanded independent travel. This
     curriculum addresses the need for an individual to know and understand movement of the
     self, then movement of the self in relationship to the environment. With very young
     children concept development originates with self-awareness---his/her own body image,
     body motion and physical movement. Building upon the ability to maneuver through space
     is the need to become aware of and learn how to evaluate that space using residual vision,
     audition, touch, and environmental awareness in addition to other senses. As environments
     become more complex, moving from the home to school and from the school to the
     community, strategies and skills become more complex, requiring the acquisition of a
     variety of tools from which to draw.

        Staff Input: No concerns regarding STUDENT’s travel
         independence have been expressed by staff.
        Orientation: STUDENT is well oriented to his school,
         including all areas of common use. His spatial mapping and
         memory skills support independent travel within the school.
         He can visually identify and avoid objects within his path,
         and identify and respond to changes in depth and terrain
         when such are visually distinct.
        Body Image: STUDENT identified most of his/her major body
         parts but had difficulty with identifying forearm, upper arm,
         waist, thigh, calf, ankle, forehead. These areas are generally
         learned incidentally, which children with visual impairments
         frequently miss. STUDENT was unfamiliar with the term to
         “squat down” but was able to complete all other movement
         patterns requested.
        Laterality, Directionality, Quantitative Concepts: STUDENT
         demonstrated simple rights and lefts, turning his body
         correctly and pointing to his left arm, his right eye, etc. He
         was unable to identify laterality in others, and had specific
         challenges with terms such as shallow, narrow, wide.

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net                            9
          Directional and Positional Concepts, Colors, Shapes:
           STUDENT correctly labeled primary and secondary colors,
           primary shapes, and correctly demonstrated most positional
           concepts with the (expected) exception of parallel and

   The Hill Test of Selected Positional Concepts:
   The Hill Performance Test of Selected Positional Concepts evaluates positional concepts
   through four identified constructs: positional relationships of body parts, ability to move body
   parts to demonstrate positional relationships, ability to move body parts to demonstrate
   positional concepts to objects, and ability to form object-to-object relationships to
   demonstrate positional concepts. This test can be used as a criterion referenced test to
   identify strengths and weaknesses regarding positional concept development—often an area
   of difficulty for students with visual impairments---or as norm-referenced test for congenitally
   visually impaired or blind children, who may or may not have additional disabilities.
  This test was administered in a quiet empty conference room on
  DATE. During this test _________was asked to position parts of
  his body and objects in spatial relationship to one another.
  Questions were repeated until ______initiated movement.
  _______cooperated with the examiner at all times and did not ask
  questions to be repeated—although questions to which he did not
  respond immediately were repeated until he initiated movement.
  Out of 144 possible points, _________--scored _____points,
  placing her in the ____th percentile of
  _______________congenitally visually impaired or blind students
  who take this test. Be careful how you discuss results—
  percentile ranking is NOT the same as percentages, AND a
  percentile ranking of 26th-75th is considered within the
  average range.
  On subtest construct I evaluating the ability to identify positional
   relationships of body parts, _______ scored in the __th
   percentile, missing questions regarding conceptual issues such as
   farthest away, nearest to. On subtest construct II evaluating the
   ability to move various body parts in relationship to each other
   _________had difficulty with moving body parts to make parts
   lower than and centering between, which was NOT a matter of
   terminology as much as a matter of motor planning. On subtest
   construct III evaluating the ability to move the body in
   relationship to objects to demonstrate positional concepts
   ______ scored in the 75th percentile, her score reflecting the

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net                             10
     impact of multi-step planning (move yourself so the chair is
     below you). Subtest construct IV evaluates the ability to form
     object-to-object relationships to demonstrate positional
     concepts—_______scored in the 90th percentile in this area. She
     demonstrated little difficulty with manipulating three objects to
     represent positional relationships, but “talked” herself through
     the process, being very deliberate in her movements. Overall
     ______’s scores indicate strength in demonstrating object-to-
     object positional relationships, with the area of greatest need in
     evaluating and demonstrating body movement in relationship to
     objects. This is consistent with the issues of movement that
     someone with impaired depth perception might experience.

 The Body-Image of Blind Children (Cratty & Sams):
 Using Cratty’s Body Image of Blind Children _______was screened
 for his understanding of body planes, body parts, body movements,
 directionality, as well as laterality in relation to self, objects, and
 others. Although there are no norms associated with this screening,
 _________ demonstrated a solid understanding of the above, with a
 mature understanding and application of laterality.

SUMMARY: Restate an abbreviated background regarding student
and then summarize findings according to category. (Visual
acuity/diagnosis, additional disabilities, medical complications and
motor complications affecting travel, audiology status and method of
communication, cane/mobility skills, concepts development according
to testing. Discuss implications. Address purpose of report.
(justification for service? Initial assessment? In response to
incident?) Describe areas of weakness and areas of strength. Explain
student interests/parent interests for service focus. Describe student

 1. Recommended IEP goal and objective with provider support
    strategies attached.
 2. Functional Vision- comment on what team needs to know

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net   11
 3. All members of STUDENT’s educational team should have access
    to in-service or consult with a Teacher of the Visually Impaired
    and an Orientation and Mobility Specialist. This consult should
    extend to specialists and be provided to his team on an annual
 4. Environment—Within the report (page X) is a list of
    environmental modifications that should be addressed to support
    safe independent travel for this student at the ______School and
    his/her home. Please forward questions/concerns regarding these
    environmental recommendations to me as soon as possible. The
    school and playground facilities should be annually reviewed by
    an Orientation and Mobility Specialist for providing access to a
    student with visual impairment.
 5. Eye exams---Please provide updated visual reports to the
    Teacher of the Visually Impaired and Orientation and Mobility
    Specialist as obtained.
 6. Sunglass/visor/hat---_____should be encouraged to wear
    sunglasses as well as a hat with a brim to reduce glare and
    maximize functional vision when outside at school and in the
 7. Transportation accessibility---Recommendations if any.
 8. The Expanded Core Curriculum (ECC) identifies nine additional
    areas beyond academics for which students with visual
    impairments and/or blindness require direct and supportive
    instruction. The team should review these areas to identify
    strategies for supporting ________in development of needed.
 9. Because audition is usually the secondary sense used for making
    travel decisions (crossing streets, etc.) in the absence or
    impairment of vision, STUDENT should have a complete
    audiological exam and results provided to his educational team.
 10. Fire Evacuation planning- STUDENT should practice exiting via
    all available exits from classroom and all rooms of common use
    to ensure identification of obstacles and depth changes,
    familiarity with route, familiarity with meeting place. STUDENT
    should also practice these routes at home.
 11. Please forward ophthalmology, audiology, physical therapy,
    occupational therapy, and incident reports (for incidents related
    to O&M- movement, balance, orientation, protection, etc.) to this

Antinarelli and Robertson, Boston AER August 2011 mjant@charter.net   12
    reporter for review. The findings will contribute directly to the
    development of future recommendations and appropriate
    trainings for STUDENT’s educational team.
 12. The Expanded Core Curriculum is the curriculum beyond
    standard academics for which students with visual impairments
    require direct intervention and instruction due to the dearth of
    acquired visual and incidental learning. These key areas include
    O&M skills, social, independent living, recreation and leisure
    skills, career education and self-determination skills, assistive
    technology and sensory efficiency skills. The team must consider
    and include these skills within the IEP planning process.
    Additional resources regarding the ECC are attached and further
    information may be found at www.afb.org , www.tsbvi.edu
 13. Please refer to the following Resources:

    NAPVI: http://www.spedex.com/napvi/
     The National Association for Parents of Children with Visual Impairments
     (NAPVI) is a non-profit organization of, by and for parents committed to
     providing support to the parents of children who have visual impairments.
    MAPVI: http://www.viguide.com/mapvi/
      Massachusetts Association for Parents of the Visually Impaired, a
     Massachusetts non-profit organization dedicated to sharing information
     and resources relating to visually impaired children. MAPVI is an affiliate of
     NAPVI, the National Association for Parents of the Visually Impaired.

NH Vision Education: The Expanded Core Curriculum from
Sighted Guide Brochure (either standardized or include website within
ADA Recommendations (if needed)
IEP Goal and Service Recommendations
  Eye Glasses/Sunglasses: note condition of and make of current eyewear, and needed
    recommendations for the assistance in the ongoing maintenance and cleaning of eyeglasses
    and sunglasses. Individual may also need assistance in tightening glasses or replacing
    screws if lost, by using an eyeglass repair kit. When eyeglasses or sunglasses require
    cleaning, they should be washed with warm water and a non-abrasive soap, and dried with
    a soft cotton cloth. Comment on use of bands, proper storage and location, labeling of
    glasses, detailing under what conditions they are worn etc.
  Eye Surgery: make team aware of need for sensitization prior to eye surgery, plan of care
    for after surgery. Assist with checking tolerance of eye patch if one will be worn after
    surgery. Need to comment on impact on vision/travel, need for any increased assistance,
    etc. On which side the guide should travel.

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