Student Name _______________________________________ Date ____________________

 

D.O.B. ___________________School ______________________  Grade________________

 

Parent/Guardian ________________________Phone (H)___________(W) _____________

__________________________                 ___________________________
Psychologist Signature                                 Resource Teacher Signature

1. When was the most recent school vision screening completed? ____________________

2. Do health records indicate a previously diagnosed vision problem? ___________________

3. Has the student had a vision examination performed by an ophthalmologist? __________

(attach copy, if available)

4. Given appropriate seating, is this student able to see the chalkboard? _______________

5. Does this student have difficulty reading regular textbook print? ___________________

6. Have the parents been notified of this request for assistance? ______________________

7. Is this student currently receiving Special Programs services? _____________________

(Please list) _________________________________________________________________

___________________________________________________________________________

8. Please state the specific reason for this request.
___________________________________________________________________________

___________________________________________________________________________

9. Please describe any specific behaviors that you feel might be caused by a vision problem.
___________________________________________________________________________

___________________________________________________________________________

10. Please describe interventions that have been attempted with this student.
___________________________________________________________________________

___________________________________________________________________________