Checklist Of Visual Behavior

ADVERTISEMENT

Checklist of Visual Behavior
Page 1 of 2
SAN DIEGO UNIFIED SCHOOL DISTRICT
Student Name: _____________________________________
Grade: ___________ School: _________________________
ID#: ______________________________________________
Teacher: ______________________Class_________________
Date: ____________________________________Pre / Post
SpEd Program: _____________________________________
Completed by: _____________________________________
Does the student have a current prescription for
A
YES
NO
corrective lenses?
If yes, circle when corrective lenses are required
Close-up work
Distance work
Full Time
Unsure
How often does the student wear his/her glasses as
B
Not at all
1-25%
26-50%
51-75%
76-100%
prescribed in class?
Observed visual behaviors may be affected if a child has corrective lenses and wears these lenses less than 75% of time prescribed.
If a child has corrective lenses, student should wear lenses for visually related assessments as appropriate.
************************************************************************************************************************
NOTE: Shaded items (1 - 13) are indicative of possible visual acuity or other medically related visual issues that should be
screened by the school nurse.
Directions: Please rate each behavior in the chart below. Do not leave any item blank.
Description of Visual Behavior
Not
Sometimes
Occasionally
Frequently
Always
Visual Efficiency
Observed
1-2 X’s per
3-5 X’s per week
1-3 X’s per
3 or more X’s
(Within each item circle all behaviors that apply)
Not seen
week
day
per day
Covers/closes one eye or turns head to view
1.
objects or when reading
Rubs eyes when reading
2.
Complains of eyestrain
3.
Complains of headaches, nausea, dizziness,
4.
upset stomach (circle)
Complains of double vision
5.
Complains of words moving on page
6.
Poor ball skills affecting P.E. performance
7.
Student moves to the front of the room when
8.
viewing from a distance
Complains of blurred vision (generally) close
9.
up
Complains of blurred vision when looking
10.
from desk to board
Holds things very close
11.
Moves things away from face for reading and
12.
writing tasks
Squints when looking at objects
13.
Short attention span when reading or copying
14.
Loses place when reading
15.
Omits or repeats letters, words, lines, or
16.
numbers when copying or reading
Must use finger to guide or keep place when
17.
reading
Inattentive when reading or writing
18.
Loss of reading comprehension after
19.
10 min. sustained reading
SAN DIEGO UNIFIED SCHOOL DISTRICT
REV: Sept 2010, Feb2012; PG, LS, AS, AG
Developed by P. Gahan, L. Silao, A. Stead; Adapted and modified from “Symptom Questionnaire” & “CITT” Questionnaire by M. Scheiman, OD, COVD, FAAO and “VT Checklist” from San Diego Unified School District.
Checklist_of_Visual_Behaviors_REV_26Feb2012.doc

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Life
Go
Page of 2