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									VISION SEVERITY CHARACTERISTICS WORKSHEET FOR STUDENTS WITH ADDITIONAL IMPAIRMENTS Student: ________________________________________ School: ______________________________ Visual Diagnosis: _________________________________________ Date: ________________________ Teacher of the VI: ______________________________________________________________________
Category 0-2 Mild Visual Needs 3-4 Moderate Visual Needs 5-6 Severe Visual Needs
Medically identified vision problem, with impaired ability to attend to visual stimuli Visual skills flucuate depending on activity Frequent response to stimulation/ instruction

7-8 Profound Visual Needs
Medically identified vision problem resulting in profound loss of vision Totally blind-no input

Severity Score Date|Date|Date

1. Visual Status

No medically identified Medically identified vision vision problem, but ability to problem, with ability to attend to visual stimuli is attend to visual stimuli questionable New visual skills being introduced or developed Occassional response to stimulation/ instruction Classroom participation is occasionally affected by vision loss

2. Functional Visual Visual skills being maintained/reinforced in a Status variety of settings 3. Response to Minimal response to Stimulation/ stimulation/ instruction Instruction 4. Educational Need not affected by vision loss 5. Educational Growth 6. Potential for Improved Use of Vision 7. Physical Independence
Classroom participation is

Consistent response to stimulation/ instruction

Classroom participation Classroom participation is frequently affected by is consistently affected vision loss by vision loss Demonstrating growth but on a plateau Some improvement appears possible, gains probable with vision services Dependent on a modified environment, difficulty with certain activities Continues to demonstrate steady growth Prognosis for improved visual functioning appears to be good

No measurable gains even Minimal growth even after after intervention intervention Minimal, gains appear remote Currently functioning at a level equal to developmental ability

Dependent on special care Dependent on others for for medical and daily living daily living functions functions

Basically independent


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