(To be completed yearly)
Student Name: ___________________________________
School: _________________________________________
Grade Level: _______ Age: ______ TVI: ____________________
Date of Needs Assessment: ________________________________
Check all who contributed to this Needs Assessment:
| Parents | General Education Teacher | COMS | |||
| Student | Special Education Teacher | Other related service providers | |||
| Other Family Members | TVI | Administrators |
Key: (+) Strength (-) Need (0) Not a Need at this time
Circle or highlight Priority Areas
| Skills | Key | Justification Statement |
|---|---|---|
| COMPENSATORY/ACCESS | ||
| Communication & Type | ||
| Handwriting | ||
| Tactual Readiness | ||
| Braille reading, including fluency | ||
| Braille writing | ||
| Nemeth code | ||
| Slate and stylus | ||
| Effective use of optical devices for literacy (see visual efficiency) | ||
| Calculator | ||
| Abacus | ||
| Listening Skills | ||
| Organization | ||
| Study & Reference Skills | ||
| Use of live reader | ||
| Use of charts, graphs, maps | ||
| Scientific Notation | ||
| Music Notation | ||
| Needed Accommodations | ||
| Additional Areas (identify) | ||
| CAREER EDUCATION | ||
| Knows function of community workers | ||
| Follows simple/complex classroom & school rules | ||
| Initiates & completes school assignments on time | ||
| Demonstrates concern for quality of work | ||
| Identify educational service options related to visual impairment | ||
| Develop statement on eye condition & needed accommodations | ||
| Assume responsibility for obtaining supplies, resources | ||
| Explore realistic options for future education/career programming | ||
| Additional Skills (identify) | ||
| INDEPENDENT LIVING SKILLS | ||
| Dressing/Clothing Management | ||
| Personal Hygiene/Grooming | ||
| Toileting and Feminine Hygiene | ||
| Eating/Food Management | ||
| Housekeeping & Home Maintenance | ||
| Obtaining & Using Money | ||
| Time Concepts | ||
| Health & Safety | ||
| Additional Skills (identify) | ||
| ORIENTATION AND MOBILITY | ||
| Concept Development | ||
| Body Image | ||
| Protective Techniques | ||
| Sighted Guide | ||
| Trailing | ||
| Search Patterns | ||
| Cane Skills | ||
| Independent Travel in Familiar Environments | ||
| Independent Travel in Unfamiliar Environments | ||
| Public Transportation | ||
| Requesting Assistance | ||
| Use of Distance Optical Devices | ||
| Additional Skills (identify) | ||
| RECREATION/LEISURE | ||
| Management of Leisure Time | ||
| Solitary Play & Leisure Activities | ||
| Physical Games & Sports | ||
| Pets & Nature | ||
| Music & Dance | ||
| Arts & Crafts | ||
| Drama | ||
| Science & Technology | ||
| Additional skills (identify) | ||
| SELF-DETERMINATION | ||
| Self-Awareness | ||
| Decision Making | ||
| Problem-Solving | ||
| Goal Setting & Attainment | ||
| Self-Observation, Evaluation, & Reinforcement | ||
| Self-Instruction | ||
| Choice Making | ||
| Positive Self-Efficacy and Outcome Expectancy | ||
| Self-Advocacy, & Leadership | ||
| Self-Understanding | ||
| Facilitation of IEP & Team Meeting | ||
| Able to describe and explain eye condition | ||
| Additional skills (identify) | ||
| SENSORY EFFICIENCY | ||
| VISUAL | ||
| Chooses a device appropriate for the visual task (near/distance) | ||
| Communicates purpose & function of prescribed optical device | ||
| Demonstrates daily maintenance of optical devices | ||
| Initiatives independent use of optical device | ||
| Demonstrates knowledge of prescribed optical device | ||
| Demonstrates proficiency with prescribed optical device | ||
| Demonstrates fluency (reading/writing) with optical device commensurate w/ classroom peers (see ECC Resource Guide) | ||
| AUDITORY | ||
| Discrimination | ||
| Association | ||
| Short term memory | ||
| Long term memory | ||
| Listening for meaning | ||
| Skills for using taped materials/listening experiences | ||
| TACTUAL | ||
| Explores tactually | ||
| Recognizes tactile characteristics of objects | ||
| Interprets tactile stimuli | ||
| Interprets graphic information | ||
| Additional Skills (identify) | ||
| SECONDARY LEARNING SKILLS | ||
| Olfactory | ||
| Gustatory | ||
| Kinesthetic | ||
| Other Skills | ||
| SOCIAL INTERACTION SKILLS | ||
| Interaction with Family, Peers, & Others | ||
| Non-verbal communication | ||
| Courteous Behavior | ||
| Personal & Civic Responsibility | ||
| Recognition & Expression of Emotions | ||
| Personal & Social Aspects of Sexuality | ||
| Additional Skills (identify) | ||
| TECHNOLOGY | ||
| Computer | ||
| Keyboarding | ||
| Use of screen reader | ||
| Braille technology | ||
| Voice output technology | ||
| Screen enlargement | ||
| Managing/Securing Equipment | ||
| Use/management of Electronic Texts | ||
| Additional Skills (identify) | ||
| OTHER CONCERNS | ||
| Fine Motor | ||
| Gross Motor | ||
| Speech and language | ||
| Hearing | ||
| Behavior(s) | ||
| Additional Skills (identify) |
** Teacher discretion is required for skill sets identified within each content area.
Developed by Wendy Sapp & Iowa ECC Resource Team
Revised by Karen Blankenship, 2009