Checklist Of Visual Behavior Page 2

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Checklist of Visual Behavior
Page 2 of 2
SAN DIEGO UNIFIED SCHOOL DISTRICT
Description of Visual Behavior
Not
Sometimes
Occasionally
Frequently
Always
Visual Processing
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
Trouble discriminating left from right
20.
Reverses letters, numbers or words when
21.
copying or writing
Mistakes words with similar beginnings
22.
when reading
Can’t recognize the same word repeated on a
23.
page
Poor recall of visually presented material
24.
Trouble with spelling and sight vocabulary
25.
Sloppy writing skills
26.
Can respond orally but not in writing
27.
Seems to know material but does poorly on
28.
written tests
Misaligns numbers in columns, during math
29.
tasks
Difficulty orienting letters (positioning)
30.
appropriately on or between lines
Poor spacing of letters w/in words or words
31.
w/in a sentence when writing
Difficulty copying near point (e.g. from book
32.
to paper)
Difficulty finding items in cluttered area
33.
(e.g. desk, backpack, room)
Has more difficulty organizing desk space or
34.
backpack than peers
Difficulty copying from far point
35.
(e.g. board to paper on desk)
Erases excessively
36.
Reading comprehension difficulties
37.
Difficulty identifying specific letter, number
38.
or word
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

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