COMPONENT 5




POSTURE & MOVEMENT COMPONENTS
OF VISUAL FUNCTION

Name: Date of Birth:
Date of ISAVE: Age at Observation:
Visual Diagnosis: Medications:
Additional Impairments:  
Low Vision Aids:  
Low vision prescription: _______ Lenses worn Check Box yes Check Box no


  POSTURAL TONE Check Box normal Check Box abnormal
  Check Box high tone Check Box low tone Check Box fluctuating tone


  POSTURAL SKILL WNL DEFICIT COMMENTS
HEAD/NECK COMPONENTS      
  Head righting Check Box Check Box  
  Head rotation Check Box Check Box  
  Head aligned with trunk in all postures Check Box Check Box  
  Head and neck aligned Check Box Check Box  
  Head posture stable in all positions Check Box Check Box  
  Normal, strong sucking Check Box Check Box  
SHOULDER GIRDLE COMPONENTS      
  Scapula stable on spine Check Box Check Box  
  Supports weight on forearms in prone, shoulder align over body Check Box Check Box  
  Shifts weight laterally while prone on forearms Check Box Check Box  
UPPER EXTREMITY COMPONENTS
      
  Brings hands to mouth Check Box Check Box  
  Grasps objects Check Box Check Box  
  Brings objects toward and away from eyes Check Box Check Box  
  Grasps feet Check Box Check Box  
  Bears weight on hands Check Box Check Box  
TRUNK COMPONENTS
      
  Trunk stability Check Box Check Box  
  Dissociation of trunk from pelvis Check Box Check Box  
  Shifts from and returns to midline in prone and sitting Check Box Check Box  
  Midline organization Check Box Check Box  
  In supine, brings hands to feet Check Box Check Box  
  Lateral trunk flexion in sidelying Check Box Check Box  
  Trunk rotation Check Box Check Box  
MOVEMENT SKILLS
      
  Rolls segmentally Check Box Check Box  
  Stable in sitting Check Box Check Box  
  Anterior/posterior weight shift in four-point Check Box Check Box  
  Creeps in four-point Check Box Check Box  
  Rotation in sitting Check Box Check Box  
  Shifts between sitting and four-point Check Box Check Box  


SUMMARY & RECOMMENDATIONS: Evaluator: ___________________


Highest level motor skill(s)

Posture/movement components that most interfere with visual functioning:

Posture/movement components needed to enhance/integrate visual functioning:



Primary Care Physician:_____________________________:
cc:







APPARENT LIGHT PERCEPTION


Name: Date of Birth:
Date of ISAVE: Age at Testing:
Visual Diagnosis: Prescribed Aids:
Medications: Additional Impairments:

Other relevant medical information:		  


ELICITING CONTEXT NATURE AND QUALITY OF VISUAL RESPONSE
FACILITATED CONTACT   Source: Direct/Illuminated
Check Box Does not respond   Quality: Steady/Intermittent/Color
Check Box alerts    
Check Box orients Contrast lighting: Natural/Dim/Blacklight/Projected
Check Box localizes Distance: Near/Far
Check Box reaches Field: Central/Peripheral
Check Box activates  
Eye Chart
Check Box shifts
Check Box moves toward
Check Box pursues
 
 
 
 
 
 
 
Activity:


IMPOSED LIGHT   Source: Direct/Illuminated
Check Box Does not respond   Quality: Steady/Intermittent/Color
Check Box alerts    
Check Box orients Contrast lighting: Natural/Dim/Blacklight/Projected
Check Box localizes Distance: Near/Far
Check Box reaches Field: Central/Peripheral
Check Box activates  
Eye Chart
Check Box shifts
Check Box moves toward
Check Box pursues
Check Box searches
Check Box scans
Check Box discriminates
 
 
 
 
Activity:


ELICITING CONTEXT NATURE AND QUALITY OF VISUAL RESPONSE
MOTION AGAINST LIGHT   Source: Direct/Illuminated
Check Box Does not respond   Quality: Steady/Intermittent/Color
Check Box alerts    
Check Box orients Contrast lighting: Natural/Dim/Blacklight/Projected
Check Box localizes Distance: Near/Far
Check Box reaches Field: Central/Peripheral
Check Box activates  
Eye Chart
Check Box shifts
Check Box moves toward
Check Box pursues
Check Box searches
Check Box scans
Check Box discriminates
 
 
 
 
Activity:


FORM AGAINST LIGHT   Source: Direct/Illuminated
Check Box Does not respond   Quality: Steady/Intermittent/Color
Check Box alerts    
Check Box orients Contrast lighting: Natural/Dim/Blacklight/Projected
Check Box localizes Distance: Near/Far
Check Box reaches Field: Central/Peripheral
Check Box activates  
Eye Chart
Check Box shifts
Check Box moves toward
Check Box pursues
Check Box searches
Check Box scans
Check Box discriminates
 
 
 
 
Activity:


ELICITING CONTEXT NATURE AND QUALITY OF VISUAL RESPONSE
DETAIL AGAINST LIGHT   Source: Direct/Illuminated
Check Box Does not respond   Quality: Steady/Intermittent/Color
Check Box alerts    
Check Box orients Contrast lighting: Natural/Dim/Blacklight/Projected
Check Box localizes Distance: Near/Far
Check Box reaches Field: Central/Peripheral
Check Box activates  
Eye Chart
Check Box shifts
Check Box moves toward
Check Box pursues
Check Box searches
Check Box scans
Check Box discriminates
 
 
 
 
Activity:

SUMMARY



Most consistent level of response:

Optimal type and quality of light:

Optimal level of illumination contrast:

Optimal visual fields:

Optimal working distances:   near ______ far ______

Types of activities that consistently elicited visual behavior:





Evaluator: ____________________________________
Primary Care Physician and /or Eye Care Physician: ________________________


COMPONENT 6




ALIGNMENT & OCULAR MOBILITY

Name: Date of Birth:
Date of ISAVE: Age at Observation:
Visual Diagnosis: Medications:
Additional Impairments:  
Low vision prescription: _______ Lenses worn Check Box yes Check Box no

HIRSCHBERG CORNEAL LIGHT REFLECTION TEST

Alignment WNL Check Box Yes  Check Box No Position of Reflection
    Right Left 
Strabismus Type:   Oval Oval
Check Box Pseudostrabismus
Check Box Phoria
Check Box Tropia   Check Box comitant   Check Box incomitant Right Left 
Check Box Alternating (complete second diagram to reflect alternate position of reflection) Oval Oval
Nature of Strabismus OS   OD    OS Comments
Esotropia Check Box    Check Box     Check Box    
Exotropia Check Box    Check Box     Check Box    
Hypotropia Check Box    Check Box     Check Box    
Hypertropia Check Box    Check Box     Check Box    

POSTURAL COMPENSATIONS

Head Position Eye Position Comments & Direction


Most typical posture

OD

OS		  
  Oval Oval  
Check Box hyperextended  
Check Box flexed      
Check Box rotated     Check Box right   Check Box left
Check Box laterally flexed     Check Box right   Check Box left
Position in which eyes most aligned OD OS  
  Oval Oval  
Check Box hyperextended  
Check Box flexed      
Check Box rotated     Check Box right  Check Box left
Check Box laterally flexed     Check Box right  Check Box left
When head alignment is imposed/facilitated OD OS  
  Oval Oval  


COVER TESTS

Cover/Uncover WNL Check Box Yes Check Box No Check Box Phoria  Check Box Strabismus
Alternating Cover WNL Check Box Yes Check Box No Check Box Phoria  Check Box Strabismus
Nature of Strabismus OU OD OS Comments
  Esotropia Check Box Check Box Check Box  
  Exotropiz Check Box Check Box Check Box  
  Hypophoria Check Box Check Box Check Box  
  Hyperphoria Check Box Check Box Check Box

Nature of Phoria OU OD OS Comments
  Esotropia Check Box Check Box Check Box  
  Exotropiz Check Box Check Box Check Box  
  Hypophoria Check Box Check Box Check Box  
  Hyperphoria Check Box Check Box Check Box

Additional Observations:


EYE MOBILITY

Assess each eye independently from the fellow eye, occluding the eye not being assessed. From a distance of approximately 12 inches, move a stimulus above, below, temporally, and nasally, past the nose opposite the eye being assessed. Allow the student time to adjust to the occlusion prior to recording responses.

Eye(s) Eye Movement Comments
  Abducts Adducts Elevates Depresses  
OU Check Box Check Box Check Box Check Box  
OD Check Box Check Box Check Box Check Box  
OS Check Box Check Box Check Box Check Box  
Check Box Both eyes move equally with regard to fluidity of movement and response time
Check Box Right eye is more efficient
Check Box Left eye is more efficient

Additional Observations



OCULOCEPHALIC INTEGRATION

Gently cradle the head in the palm of your hands and steadily move the head so that 1) the chin is flexed toward the chest, 2) the chin is elevated approximately 30 degrees, 3) the chin is rotated to the right shoulder, 4) the chin in rotated to the left shoulder, 5) the left ear is laterally flexed toward the left shoulder, and 5) the right ear is laterally flexed toward the right shoulder.

Head/Neck Movement Vestibulo-ocular Response Comments
  Integrated Immature  
Head/neck flexion Check Box Check Box  
Head/neck extension Check Box Check Box  
Head/neck rotation Check Box Check Box  
Head/neck lateral flexion Check Box Check Box  

COMPONENT 7




OCULOMOTOR SKILLS


Name: Date of Birth:
Date of ISAVE: Age at Observation:
Visual Diagnosis: Low vision prescription: _______ Lenses worn Check Box yes Check Box no
Additional Impairments:  
Medications:  


FIXATION

IndicatesCheck Mark each behavior that characterizes current visual function in the appropriate column (OU = both; OD = right; OS = left). Indicate emerging or inconsistent responses with an E (emerging) but also indicate that the skill is not (No) considered mastered within the student's repertoire. Behaviors prior to the student's level of functioning are considered integrated. If the behavior is clearly not within the student's repertoire, indicate Check Mark the No column. Record the distance the stimulus is from the student when fixated and any quality or description of responses that will facilitate accurate interpretation and intervention planing.

Level of Functioning No OU OD OS Distance/Comments
  1. Eyes open/drift
 Check Box Check Box Check Box Check Box  
  1. Eyes open/shift
 Check Box Check Box Check Box Check Box  
  1. Alerts to stimuli
 Check Box Check Box Check Box Check Box  
  1. Orients to stimuli
 Check Box Check Box Check Box Check Box  
  1. Monocular/fleeting
 Check Box Check Box Check Box Check Box  
  1. Binocular/brief
 Check Box Check Box Check Box Check Box  
  1. Head movement interrupts fixation
 Check Box Check Box Check Box Check Box  
  1. Fixation "stuck"
 Check Box Check Box Check Box Check Box  
  1. Regains fixation/latency
 Check Box Check Box Check Box Check Box  
  1. Regains fixation/promptly
 Check Box Check Box Check Box Check Box  
  1. Localizes/6 cardinal gaze positions
 Check Box Check Box Check Box Check Box  
  1. Fixation stable/looking
 Check Box Check Box Check Box Check Box  
  1. Fixation stable on reach/move
 Check Box Check Box Check Box Check Box  
Stimuli/Size:______ Stimuli/Size:______ Stimuli/Size:______


POSTURAL INFLUENCES ON FIXATION

IndicateCheck Mark the position(s) in which oculomotor skills were optimal
Position: Check Box supine Check Box prone Check Box sidelying  
  Check Box sitting Check Box standing
Check Box special equipment /positioning _____________________________
Is there a position that is contradicated or that impeded oculomotor function? Describe:


PURSUIT

IndicatesCheck Mark each behavior that characterizes current visual function in the appropriate column (OU = both; OD = right; OS = left). Indicate emerging or inconsistent responses with an E (emerging) but also indicate that the skill is not (No) considered mastered within the student's repertoire. Behaviors prior to the student's level of functioning are considered integrated. If the behavior is clearly not within the student's repertoire, indicate Check Mark the No column.

On the relevant diagram(s), mark(X) the position(s) in which pursuit was lost or an eye(s) moved out of alignment. Qualify the Mark(X) by description and direction of movement. Initiate pursuit from both the left and the right several consecutive cycles.

Right to Left Left to Right Physiological H
Right to Left Eye Pursuit Diagram Left to Right Eye Pursuit Diagram H Eye Pursuit Diagram


Pursuit Behaviors No OU OD OS Distance/Comments
  1. Peripheral/jerky movement in direction of stimulus
 Check Box Check Box Check Box Check Box  
  1. Periphery toward midline (30-60)
 Check Box Check Box Check Box Check Box  
  1. Periphery/past midline/lags
 Check Box Check Box Check Box Check Box  
  1. Central/refixates H/V
 Check Box Check Box Check Box Check Box  
  1. Central/90-120 degrees
 Check Box Check Box Check Box Check Box  
  1. Central/horizontal/vertical
 Check Box Check Box Check Box Check Box  
  1. Central 180/loses midline
 Check Box Check Box Check Box Check Box  
  1. Central 180/smooth
 Check Box Check Box Check Box Check Box  
  1. Physiological H/smooth
 Check Box Check Box Check Box Check Box  


EYE-HEAD PATTERNS DURING PURSUIT

  Horizontal Vertical Diagonals Comments
Eyes primarily (> 20/70) Check Box Check Box Check Box  
Head and eyes (> 20/100) Check Box Check Box Check Box  
Head primarily (> 20/200) Check Box Check Box Check Box  
Pursuit not achieved Check Box Check Box Check Box  


BINOCULAR VISION

IndicatesCheck Mark each behavior that characterizes current visual function in the appropriate column (OU = both; OD = right; OS = left). Indicate emerging or inconsistent responses with an E (emerging) but also indicate that the skill is not (No) considered mastered within the student's repertoire. Behaviors prior to the student's level of functioning are considered integrated. If the behavior is clearly not within the student's repertoire, indicate Check Mark the No column. Record the distance the stimulus is from the student when fixated and any quality or description of responses that will facilitate accurate interpretation and intervention planing.


BINOCULAR VISION

Binocular Skills No OU OD OS Distance/Comments
  1. Mild degree of exotropia
 Check Box Check Box Check Box Check Box  
  1. One eye turns in intermittently
 Check Box Check Box Check Box Check Box  
  1. Eye(s) turn in on hand/object
 Check Box Check Box Check Box Check Box  
  1. One eye /other fixates stimulus
 Check Box Check Box Check Box Check Box  
  1. Ocular alignment stable
 Check Box Check Box Check Box Check Box  
  1. Coordinates gaze sideways
 Check Box Check Box Check Box Check Box  
  1. Eyes move conjugately, all directions
 Check Box Check Box Check Box Check Box  
  1. Converges eyes on objects in hand
 Check Box Check Box Check Box Check Box  
  1. Binocular convergence 2-3 inches
 Check Box Check Box Check Box Check Box  
  1. Depth perception intact
 Check Box Check Box Check Box Check Box  


OCULOMOTOR QUALITY INDICATORS

General Quality: Check Box organized Check Box emerging Check Box disorganized
Eye/Head Dissociation: Check Box eye-head movements integrated Check Box eyes move with head
  Check Box eyes leads Check Box head leads
Pursuit: Check Box organized Check Box emerging Check Box localizes primarily
  Check Box follows better left to right Check Box follows better right to left
Visual Compensations: Check Box close one eye Check Box one eye leads Check Box adducts an eye
  Check Box adopts abnormal head/neck posture
  Check Box jerks head to elicit movement
Check Box Eyes Aligned Check Box Strabismus Check Box Phoria


Head Posture Face /Chin Posture Eye Posture
    OD   OS
    Check Box aligned Check Box
Check Box  Hyperextended   Check Box esotropic Check Box
Check Box  Flexed   Check Box exotropic Check Box
Check Box  Rotated R  L   Check Box hypertropic Check Box
Check Box  Laterally flexed R  L   Check Box hypotropic Check Box

Additional observations:







COMPONENT 8




VISUAL ACUITY


Name: Date of Birth:
Date of ISAVE: Age at Observation:
Visual Diagnosis: Low vision prescription: _______ Lenses worn Check Box yes Check Box no
Additional Impairments:  
Medications:  


NEAR POINT MINIMAL OBSERVABLE

Stimulus Size Distance Description/
    <4-8" <12-18" >12-18" <3" Comments
 Candy/Bread Test            
 Patterns/pictures            
 Patterns            
 Pictures/different color            
 Pictures/same color            
 Stylized picture            
 2D to Picture match            
 Black & white picture            
 Photographs            
 One-inch/high contrast            
 One-inch/low contrast            
 Representational match            



FAR POINT MINIMAL OBSERVABLE

Stimulus Size Distance Description/
    >30" <3' <5' <10' <15' <20' Comments
 Retrieval of light                
 Retrieval of objects                
 Object detection                
 Picture detection                
 Acuity estimation card                
 Detection of color                


Check Box  Rotates head Check Box  right Check Box  left    
Check Box  Tilts head Check Box  right Check Box  left Check Box  forward Check Box  backward
Check Box  Adducts eye Check Box  OD Check Box  OS    
Check Box  Holds objects close        
Check Box  Holds objects at distance        
Check Box  Leans forward        
Check Box  Squints        
Check Box  Closes one eye Check Box  OD Check Box  OS    
Check Box  Resists covering one eye Check Box  OD Check Box  OS    
Check Box  Other ____________________________  

COMPONENT 9




VISUAL FIELDS


Name: Date of Birth:
Date of ISAVE: Age at Observation:
Visual Diagnosis: Medications:
Additional Impairments:  
Low vision prescription: _______ Lenses worn Check Box yes Check Box no


PERIPHERAL FIELDS

  Right Left Motion Image Illumination Image Object Image Comments
  Yes  No Yes  No        
Eyes orient/localize Check Box     Check Box Check Box     Check Box        
lateral Check Box     Check Box Check Box     Check Box        
upper  Check Box     Check Box Check Box     Check Box        
lower  Check Box     Check Box Check Box     Check Box      

Gaze Stuck Check Box     Check Box Check Box     Check Box      

Shifts Gaze Check Box     Check Box Check Box     Check Box      

Shifts clock position            
lateral Check Box     Check Box Check Box     Check Box        
upper  Check Box     Check Box Check Box     Check Box        
lower  Check Box     Check Box Check Box     Check Box      

Scanning:Erratic/Sys.            
lateral Check Box     Check Box Check Box     Check Box        
upper  Check Box     Check Box Check Box     Check Box        
lower  Check Box     Check Box Check Box     Check Box      

Blinks to threat Check Box   yes Check Box    no      


Key:   Motion Image = motion:    Illumination Image = illumination:    Object Image = object or picture



CENTRAL FIELDS Absent Present Comments
  1. Gaze caught object agitated at midline
 Check Box Check Box  
  1. Brief fixation: both eyes on stimulus
 Check Box Check Box  
  1. Prompt regard at midline
 Check Box Check Box  
  1. Central pursuit to 90 degrees
 Check Box Check Box  
  1. Central pursuit 180 degrees
 Check Box Check Box  
  1. Shifts gaze horizontally
 Check Box Check Box  
  1. Shifts gaze foreground/background
 Check Box Check Box  
  1. Ocular alignment stable
 Check Box Check Box  
  1. Converges on toy held in hand
 Check Box Check Box  
  1. Reaches for toy held midline
 Check Box Check Box  
  1. Scans L C R fields
 Check Box Check Box  
  1. Conjugate localization
 Check Box Check Box  

Additional Observations:
Describe and note whether equipment is used




GRIDS PROTOCOL


   The extent of both peripheral and central fields are assessed with confrontation and with scanning strategies. Indicate Check mark gaze on the appropriate grid, depending on whether fields are assessed with the grids positioned vertically or horizontally in relation to the student. Indicate Check mark the purpose, nature, quality, and extent of fields in the charts below


Function Check Box Scanning Assessment Check Box Augmentative Assessment
Surface Check Box table Check Box floor Check Box lap tray
Orientation Check Box perpendicular to student Check Box upright 90 degrees
  Check Box 45 degrees from surface Check Box 30 degrees from surface
  Check Box Other ________________________
Position
of student



 Describe and note whether equipment is used


The charts should be marked as to LEFT/RIGHT; TOP/BOTTOM depending on position relative to student

Check Box peripheral

Check Box central

Check Box code		 Pie chart


Optimal ranges of visual fields: horizontal/vertical: ______ in.x ______ in.
Optimal number of cells in grid: horizontal/vertical: ______ /______
Optimal size of cells:  ______ inches
Distance needed between stimuli: horizontally/vertically: ______ /______
Average time needed to scan cells: horizontal/vertical: ______ sec. /______ sec.
Average time needed to shift gaze to new cell: horizontal/vertical: ______ /______
Most efficient path of gaze: Check Box left to right Check Box right to left
  Check Box top to bottom Check Box bottom to top
  Check Box clockwise Check Box counter-clockwise
Size of stimuli that elicited the most efficient direction of gaze: ______ in.


COMPONENT 10




CORTICAL VISUAL IMPAIRMENT
INVENTORY OF DEVELOPMENTAL
& BEHAVIOR MARKERS


Name: Date of Birth:
Date of ISAVE:  
Chronological Age: Estimated Developmental Level:
Contexts of Observations:  
Visual Diagnosis: Medications:
Additional Impairments:  


DEVELOPMENTAL HISTORY

Check Box Prenatal asphyxia
Check Box Perinatal asphyxia
Check Box Periventricular leukomalacia
Check Box Occipital infarcts
Check Box Intracranial hemorrages: Grade ______
Check Box Intrauterine infection (type) ____________
Check Box Fetal distress: __________________
Check Box Meconium staining
Check Box Bradycardia
Check Box Intubated
Check Box Meningitis/Encephalitis (circle)
Check Box Trauma (type) _________________
Check Box Hydrocephalus
Check Box Shunt malfunction (revisions) ______
Check Box Brain malformation (type) ___________
Check Box Delayed Visual Maturation

Comments/Notes:



OCULAR EXAMINATION

Check Box Normal anterior visual pathway
Check Box Abnormal posterior visual pathway/visual cortex
Check Box Normal pupillary response
Check Box Motility normal
Check Box Absence of nystagmus

Comments/Notes:



APPEARANCE

Check Box Doesn't "look" blind
Check Box Expressionless face
Check Box Eye movements smooth but aimless
Check Box Visual self-stimulation rare
Check Box Visually inattentive
Check Box Tends to look away from people and events
Check Box Diminished visual communication

Comments/Notes:



VISUAL FUNCTIONING

Check Box Visual abilities fluctuate from day to day and hour to hour
Check Box Peripheral vision appears to be more functional
Check Box Attends best to movement and to toys in motion
Check Box Appears to see better when moving
Check Box Sees better in familiar environments
Check Box Lacks visual curiosity
Check Box Spontaneously uses vision only for short periods of time
Check Box Tires easily during visual learning
Check Box Holds objects close to eyes when looking
Check Box On reaching, turns head, and may exhibit downward gaze
Check Box Vision may be better on one side: field restrictions apparent
Check Box Drawn to light sources and may engage in prolonged light gazing
Check Box Tends to be photophobic

Comments/Notes:



VISUAL PERCEPTUAL CHARACTERISTICS

Check Box Appears unable to recognize stationary objects
Check Box May not recognize faces
Check Box Needs wide spaces between objects & visual stimuli
Check Box Focuses on only one toy among several
Check Box Depth perception poor, reach is inaccurate
Check Box Identified color more easily than objects or shapes
Check Box Prefers colors over black and white
Check Box Has difficulty differentiating foreground from background

Comments/Notes:



SENSORY MODALITIES

Check Box Supplements vision with touch
Check Box Uses hand searching movements when locating objects
Check Box Appears to hear better when eyes are closed

Comments/Notes:



POSTURE AND MOVEMENT CHARACTERISTICS

Check Box Rarely bumps into objects during travel
Check Box Balance seems better when eyes are closed
Check Box Vestibular input improves visual functioning
Check Box When moving, appears to see stationary objects
Check Box Usually holds head up except when reaching for visual stimuli
Check Box Head control correlates with degree of functional vision

Comments/Notes:



IMPRESSIONS & RECOMMENDATIONS

Cortical Visual Impairment suspected/confirmed: Check Box yes   Check Box no


Recommendations: Eligible for vision services: Check Box yes   Check Box no


Other recommendations:


Referral(s): __________________________________


Evaluator: _______________________



COMPONENT 11




VISUAL PERCEPTUAL SKILLS


Name: Date of Birth:
Date of ISAVE: Age at Assessment:
Visual Diagnosis: Medications:
Low vision prescription: _______ Lenses worn Check Box yes Check Box no
Additional Impairments:  

Complete the following items based on review of items found on the DIVE that are appropriate to the student's general developmental functioning level. Depending on the developmental level, all processes may not be addressed. Each process is determined Passed (P), Emerging (E) or Absent (A) relative to the student's own developmental range of functioning.

Visual Perceptual Process P    E    A Comments
Depth Check Box    Check Box    Check Box  
Visual Closure Check Box    Check Box    Check Box  
Visual Discrimination Check Box    Check Box    Check Box  
    Social Check Box    Check Box    Check Box  
    Color Check Box    Check Box    Check Box  
    Form Check Box    Check Box    Check Box  
    Size Check Box    Check Box    Check Box  
    Pattern Check Box    Check Box    Check Box  
Visual Association Check Box    Check Box    Check Box  
Visual Memory Check Box    Check Box    Check Box  
Visual Sequencing Check Box    Check Box    Check Box  
Figure-Ground Relations Check Box    Check Box    Check Box  
    Eye-Hand Integration Check Box    Check Box    Check Box  



Developmental level most consistently mastered: B   6wk.   4mo.   8mo.   12mo.   18mo.   2yr.   3yr.   4yr.    5yr.
Developmental level emerging: B   6wk.   4mo.   8mo.   12mo.   18mo.   2yr.   3yr.   4yr.   5yr.
Perceptual strengths: Depth   Closure   Disc.   Assoc.   Memory   Sequencing   Fig-Grnd   Eye-Hand
Perceptual weaknesses: Depth   Closure   Disc.   Assoc.   Memory   Sequencing   Fig-Grnd   Eye-Hand

COMPONENT 13




SOCIAL/ATTENTIONAL GAZE


Name: Date of Birth:
Date of ISAVE: Age at Assessment:
Visual Diagnosis: Medications:
Additional Impairments:  
Low vision prescription: _______ Lenses worn Check Box yes   Check Box no


SOCIAL SKILLS Yes  No Comments
Orients toward face Check Box     Check Box  
Regards face Check Box     Check Box  
Watches speaker's eyes & mouth Check Box     Check Box  
Establishes eye contact Check Box     Check Box  
Responds with smile when socially approached Check Box     Check Box  
Recognizes caregiver Check Box     Check Box  
Eyes follow moving person Check Box     Check Box  
Social approach to mirror Check Box     Check Box  
Directs attention to objects in environment Check Box     Check Box  
Directs gaze toward point (gesture) Check Box     Check Box  
Shifts gaze between object or picture and listener Check Box     Check Box  
Additional Observations Check Box     Check Box  

ATTENDING BEHAVIORS Yes  No Comments
Gaze easily distracted by other visual stimuli Check Box     Check Box  
Gaze easily distracted by auditory stimuli Check Box     Check Box  
Difficulty maintaining attention to stimulus/task Check Box     Check Box  
Difficulty focusing on relevant stimuli Check Box     Check Box  
Difficulty integrating visual and auditory processes Check Box     Check Box  
Scanning of stimuli primarily tactual Check Box     Check Box  
Impulsive or erratic visual pursuit/scanning Check Box     Check Box  
Inappropriate visual attention Check Box     Check Box  
Additional Observations Check Box     Check Box  

SUMMARY

    
Social concerns Yes Check Box No Check Box
Attention concerns Yes Check Box No Check Box

Refer for additional diagnostic assessment: _______________________



COMPONENT 14




INDIVIDUALIZED SYSTEMATIC ASSESSMENT OF VISUAL EFFICIENCY
BABY SCREEN


Infant's Name: Parents/Caregivers:
Date of Birth: Address:
Date of Baby Screen Administration:  
Physician: Telephone:
Visual Diagnosis: Medication(s):
Eye Surgeries/Date(s):  
Corrective/Low vision Aids: Check Box no   Check Box yes
Prescription: _______ Lenses worn today Check Box yes   Check Box no
Premature Check Box yes   Check Box no
Gestation: ______ weeks    Weight: ______    Complications: ______
Corrective Age: Oxygen Check Box no   Check Box yes

Other medical concerns:


1. Behavior State during visual screen
Check Box Asleep/Drowsy
Range:		 Check Box Quiet Alert Check Box Active Alert Check Box Fussy/Irritable
Mode:		 Check Box Distressed
2. PHYSICAL STRUCTURE
Visual Structures WNL OD OS
Symmetry, size, shape of:   No/Comments No/Comments
   Globe Check Box Check Box Check Box
   Eyelids Check Box Check Box Check Box
   Pupils Check Box Check Box Check Box
   Iris, Cornea Check Box Check Box Check Box
Gaze Steady Check Box Check Box Check Box
Head/neck aligned Check Box Check Box Check Box
General eye-health status Check Box Check Box Check Box

RESPONSE TO LIGHT
P   Lid closure immediate
P   Pupils respond slowly
P   Eyes open in dim light
Nb-6wk   Eyes orient light source
2mo-4mo   Pupils respond briskly
2mo-4mo   Eyes follow light source
4mo-8mo   Eyes adapt to changes
8mo-12mo   Searches light source
8mo-12mo   Peers/creeps toward light
     
Passed Check Box Failed Check Box
Comments:


MATERIALS USED


SETTING/CONTEXT(S)



OBSERVATIONS



FIXATION/MINIMAL DETECTION
P   Eyes open, ambient
P   Fixates briefly to contrast
Nb-6wk   Fixates: only one eye
Nb-6wk   Fixates caregiver's face
Nb-6wk   Fixates motion
6wk-2mo   Fixates 2-in. target central field
6wk-2mo   Fixation sustained
6wk-2mo   Fixation stuck
6wk-2mo   Fixates at two to three feet
2mo-4mo   Fixates competing target
2mo-4mo   Fixates at five feet
2mo-4mo   Follows moving person at 10 feet
4mo-8mo   Detects 2.5 mm item at 10 inches
4mo-8mo   Changes focal length with difficulty
8mo-12mo   Changes focal length with ease
8mo-12mo   Detects 1.25 mm item at 10 inches
8mo-12mo   Detects 1/2-inch item at 10 feet
8mo-12mo   Points/gazes toward bird/airplane
Passed Check Box Failed Check Box
Comments:


PURSUIT
Nb-6wk   Pursues moving target 3-5 inches
Nb-6wk   Pursues target horizontally 30-60 degrees
Nb-6wk   Pursues target in periphery:
jerky/smooth
Nb-6wk   Pursues vertically, forehead frown
Nb-6wk   Pursues 2-inch target in central;
lags behind
Nb-6wk   Pursues centrally 90 degrees
6wk-2mo   Pursues monocularly: temporal field
6wk-2mo   Pursues monocularly: head turn
6wk-2mo   Pursues centrally past 90 degrees
6wk-2mo   Pursues vertically: 15° upward, 20° below
2mo-4mo   Pursues centrally 180 degrees
4mo-8mo   Pursues monocularly laterally & vertically
8mo-12mo   Pursues vertically, adult levels upward gaze
Passed Check Box Failed Check Box
Comments:


MATERIALS USED


SETTING/CONTEXT(S)



OBSERVATIONS



FIELDS
Nb-6wk   Fixates face
Nb-6wk   Fixates high-contrast target 3-5 in.
Nb-6wk   Orients to periphery
Nb-6wk   Gazes at target midline
     
6wk-2mo   Orients gaze 20 degrees nasally
6wk-2mo   Fixation stuck
2mo-4mo   Shifts gaze to competing target
2mo-4mo   Gazes promptly midline
4mo-8mo   Shifts gaze between competing targets
4mo-8mo   Shifts near-far with difficulty
4mo-8mo   Locates toy dropped in view
4mo-8mo   Quickly localizes fields of gaze
4mo-8mo   Shifts near-far smoothly
4mo-8mo   When held, orients downward to target
Passed Check Box Failed Check Box
Comments:


BINOCULARITY
Nb-6wk   One eye turns in
Nb-6wk   Fixates: only one eye
Nb-6wk   Coordinates gaze laterally
6wk-2mo   Pursues monocularly:
head turn
2mo-4mo   Coordinates gaze during following
2mo-4mo   Converges at 4-7 inches
4mo-8mo   Gaze stable
4mo-8mo   Converges on hand
4mo-8mo   Gazes conjugately vertically
8mo-12mo   Converges gaze on container
Passed Check Box Failed Check Box
Comments:


MATERIALS USED


SETTING/CONTEXT(S)



OBSERVATIONS



VISUAL PERCEPTION
Nb-6wk   Orients contrast/pattern
Nb-6wk   Orients reds, blues, greens
Nb-6wk   Fixates face
6wk-2mo   Prefers faces over toys
2mo-4mo   Fixates image: mirror
2mo-4mo   Orients to sound
4mo-8mo   Searches dropped toy
4mo-8mo   Piaget reach
4mo-8mo   Discriminates own toy
4mo-8mo   Reaches for toy
8mo-12mo   Peers into cup
8mo-12mo   Probes spaces
8mo-12mo   Pats/peers pictures
8mo-12mo   Plays peek-a-boo
8mo-12mo   Creeps/peers toward toy
8mo-12mo   Stacks/Drops
Passed Check Box Failed Check Box
Comments:


SOCIAL GAZE
Nb-6wk   Fixates faces
2mo-4mo   Establishes eye contact
2mo-4mo   Orients to voice
2mo-4mo   Discriminates caregiver
2mo-4mo   Smiles socially
2mo-4mo   Follows person
2mo-4mo   Fixates image: mirror
2mo-4mo   Anticipates approach
4mo-8mo   Reacts: facial expression
Passed Check Box Failed Check Box
Comments:


SCREENING RESULTS: DATE: ______ /______
Pass   Check Box    Fail   Check Box
Recommendations: Ineligible  Check Box
Monitor  Check Box
Place  Check Box
Refer other professionals ______
Evaluator:

COMPONENT 15




INDIVIDUALIZED SYSTEMATIC ASSESSMENT OF VISUAL EFFICIENCY
ISAVE VISION SCREEN


Name: Parents/Caregivers:
Date of Birth: Address:
Chronological Age: Date of ISAVE Screen:
Primary Care Physician: Medications:
Lens Prescription: Wearing Lenses Today: Check Box yes    Check Box no
Seen/Followed by Eye Care Specialists: ____________________________
Other Concerns:


   AT RISK FACTORS


Check Box  Premature
Check Box  Difficult labor
Check Box  Oxygen at birth
Check Box  Intrauterine infection (toxoplasmosis): ____________________
Check Box  Family history of vision impairment: ______________________
Check Box  Lack of visual responsiveness to caregiver
Check Box  Sensitivity to bright light
Check Box  Rubbing of eyes
Check Box  Eye turning in or out when tired, ill, stressed
Check Box  Trauma
Check Box  Head trauma
Check Box  Near drowning
Check Box  Other:

STRUCTURAL INTEGRITY

Visual Structures WNL Abnormal Comments
Symmetry, size, shape of:      
     Globe Check Box Check Box  
     Eye lids Check Box Check Box  
     Pupils Check Box Check Box  
     Iris, Cornea Check Box Check Box  
Gaze steady Check Box Check Box  
Head/neck aligned Check Box Check Box  
Eye-health Check Box Check Box  
Pupillary reactions Check Box Check Box  
     Direct Check Box Check Box  
     Consensual Check Box Check Box  
Reaction to lighting
 		 Check Box Check Box  
EYE ALIGNMENT      
     Corneal reflex Check Box Check Box  
     Cover/Uncover Check Box Check Box  
     Mobility symmetrical
 		 Check Box Check Box  
OCULOMOTOR SKILLS      
     Fixation sustained Check Box Check Box  
     Eyes coordinated Check Box Check Box  
     Mobility range Check Box Check Box  
     Following Check Box Check Box  
     Shift of gaze Check Box Check Box  
          Horizontal Check Box Check Box  
          Near-far Check Box Check Box  
     Convergence
 		 Check Box Check Box  
VISUAL FIELDS      
     Central Check Box Check Box  
     Peripheral
 		 Check Box Check Box  
ACUITY      
     Near (to 30") Check Box Check Box  
     Far (beyond 3')
 		 Check Box Check Box  
VISUAL PERCEPTION      
     Form Check Box Check Box  
     Color Check Box Check Box  
     Depth Check Box Check Box  
     Figure-ground Check Box Check Box  
     Detail Check Box Check Box  
     Visual motor skills
 		 Check Box Check Box  
VISUAL-SOCIAL SKILLS      
     Eye contact Check Box Check Box  
     Visual stereotopy Check Box Check Box  

SUMMARY
 
  Check Box  Screening Passed Check Box  Screening Failed
 
  Area(s) of Concern:
  Action Taken: Check Box  Rescreen: ______ Check Box  Refer
 
  Referral: Check Box  Primary care physician: ______________________
  Check Box  Eye Care Specialists: _____________________
  Check Box  Other:
 
  Screener: ______________________________ Date: ______ /______ /______




cc:

COMPONENT 16




ISAVE SUMMARY PROTOCOL


Name: Date of Birth: ______ /______ /______
Date of ISAVE: Age at Testing:
Visual Diagnosis: Age of Onset: ____________
Low Vision Rx: Rx worn: Check Box yes   Check Box no
Additional Impairments:  
Medications: Eye Health Professional:

Reason for Referral:


VISUAL SYSTEM FUNCTION

COMPONENT WNL Monitor Deficient
Structural Integrity Check Box Check Box Check Box
Concern:      
 
Adaptation to Illumination changes Check Box Check Box Check Box
Concern:      
 
Orientation and Mobility Check Box Check Box Check Box
Concern:      
 
Postural foundation Check Box Check Box Check Box
Concern:      
 
Alignment Check Box Check Box Check Box
Concern:      
 
Oculomotor skills Check Box Check Box Check Box
Concern:      
 
Acuity
    Near
    Far		 Check Box Check Box Check Box
Concern:      
 
Visual Fields
    Central
    Peripheral		 Check Box Check Box Check Box
Concern:      
 
Perception Check Box Check Box Check Box
Concern:      
 
Color perception Check Box Check Box Check Box
Concern:      
 
Depth perception Check Box Check Box Check Box
Concern:      
 
Delayed Visual Maturation Check Box Check Box Check Box
Concern:      
 
Cortical Visual Impairment Check Box Check Box Check Box
Concern:      
 

VISION VARIABLES


STUDENT VARIABLES


ELIGIBILITY FOR SERVICES

Is the student's visual behavior consistent with developmental level?   Check Box yes    Check Box no    Concerns:

If the student's visual behavior is consistent with developmental level, is there a manifest visual deficit?   Check Box yes    Check Box no    Concerns:

Does the student's visual deficit impede or interfere with playing, learning, working and/or efficient adaptation within leisure, instructional, vocational, and self-sufficiency contexts? Check Box yes    Check Box no

Examples of tasks that are difficult because of the effects of the visual deficit:

Can the student's visual needs be managed by other professionals with consultation from a certified vision teacher?   Check Box yes    Check Box no

Is/are the student's visual deficit(s) sufficiently significant to require direct services within a Program for Visually Impaired?   Check Box yes    Check Box no


Check Box ELIGIBLE for services    Check Box CONSULTATIVE    Check Box DIRECT
Check Box Does not require services at this time
Check Box Does not meet eligibility requirements for vision services
Check Box Refer:____________________________________________________