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					             ORIENTATION & MOBILITY SEVERITY SCALE FOR STUDENTS WITH ADDITIONAL NEEDS (O&MSRS+) Revised (Michigan 2008)
                                                     Student Performance Profile

Student:                                                                                Grade/Program:                                         Birthdate:
                                        NONE                         MILD                     MODERATE                      SEVERE                    PROFOUND
     Severity of Need
                                          0                           1                          2                             3                          4
                Distance
  Level of       Acuity            20/70 - 20/100               20/100 - 20/200             20/200 - 20/600               20/600 - LP               Light Perception         0
   Vision
                                                                                              o-   o
 (Medical)     Peripheral                                                                   30 10 field or                                                  to Nil           0
                                       No loss                      No loss                                             10o field - 1o field
                 Field                                                                       hemianopsia

                             Visual skills adequate for
                                                        Visual impairment affects Visual impairment affects Visual impairment affects Visual impairment affects
                              developmentally or age                                                                                                                         0
Level of Vision (Functional)                             ability to travel in a few ability to travel in some ability to travel in most  ability to travel in all
                             appropriate independent
                                                         selected environments            environments              environments            environments
                                       travel

                                                                                 Level of travel tool use           Level of travel tool use
 Use / proficiency of travel                           Level of travel tool use                                                                  Level of travel tool use
                                                                                moderately impacts safe             severely impacts safe                                    0
  tools (cane / Alternative Travel tool inappropriate has mild impact on travel                                                                 profoundly impacts safe
                                                                                     travel in some                     travel in most
      Mobility Device)                                and in few environments                                                                  travel in all environments
                                                                                     environments                       environments

                                                            Level of communication      Level of communication
                               Level of communication                                                               Level of communication Level of communication
                                                             significantly impacts      impacts ability to benefit                                                           0
      Communication           prevents ability to benefit                                                           minimally impacts ability is sufficient for student to
                                                             ability to benefit from    from instruction in some
                                  from instruction                                                                 to benefit from instruction benefit from instruction
                                                                    instruction                situations


                                Non-visual additional   Non-visual additional    Non-visual additional   Non-visual additional    Non-visual additional
   Non-visual additional                                                                                                                                                     0
                              needs profoundly impact needs severely impact on needs moderately impact needs have a mild impact needs have no impact on
          needs
                                  success in O&M          success in O&M           success in O&M        on success in O&M          success in O&M


                                                            Needs close supervision     Needs close supervision
    Level of supervision       Needs total assistance                                                              Needs close supervision Able to safely travel with        0
                                                            and physical prompting      and verbal prompting for
   needed for safe travel         for safe travel                                                                      for safe travel     minimal or no supervision
                                                                 for safe travel              safe travel


                                                                                                                                         Conceptual
                                Progress in O&M is       Progress in O&M is       Progress in O&M is    Progress in O&M is mildly
  Spatial / Environmental                                                                                                          understanding sufficient                  0
                              profoundly inhibited by   severely inhibited by   moderately inhibited by  inhibited by conceptual
conceptual understanding                                                                                                          for development of travel
                             conceptual understanding conceptual understanding conceptual understanding       understanding
                                                                                                                                            skills


     Compliance with             Non-compliant with         Significant time spent in    Moderate time spent in      Minimal time spent in          Cooperative and          0
       instruction                  instruction             behavior management          behavior management        behavior management               compliant


                                                                                                                                                  Severity of Need Score     0
                          ORIENTATION & MOBILITY SEVERITY SCALE FOR STUDENTS WITH ADDITIONAL IMPAIRMENTS
                                                      Student Performance Summary


Student:                                                         Grade/Program:                                   Birthdate:


                                                                                    CONTRIBUTING FACTORS TO SERVICE DELIVERY
                   RECOMMENDATIONS OF SERVICES
                                                                                    add (.5) or subtract (-.5) points for each + or -
                           Final Severity of Need
           Date                                     Frequency                           Posture, gait and motor development
                                   Score
                                     0                                                  Nature of eye disease or condition
                                                                                        Transition support needed

                                                                                        Recent vision loss

                                                                                        Potential for improvement of travel skills

                                                                                        Age of onset of visual impairment
                                                                                        Team availability for follow-up

 Severity of Need Score          Frequency                                              Instruction in low vision aids
                                                                                        Complexity or introduction of new environment
            0-2             Service not indicated                                       Community Based Instruction opportunities
                                                                                        Other (explain)
            3-4               1-5 times / year
                                                                                        Other (explain)
            5-6             3-4 times / semester
                                                                                        Other (explain)
                            1-2 times / month                                           Other (explain)
           7-12
                           20 - 60 minutes each
                                                                                        Other (explain)
                             1-2 times / week
           13-24
                           30 - 45 minutes each                                         Other (explain)
                            2 or more times/week
           25-36
                            30 - 60 minutes each
                                                                                    0

				
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