Interview Form – Teacher of a Student with CVI


1.  What is your understanding of this student’s visual impairment?



2.  What program is this student in and does this student have any other eligibilities other than Vision?  Do you have any concerns with regard to this student’s hearing?



3.  What are your concerns about this student’s vision?



4.  What is this student’s favorite toy or object that she/he most often responds to?  Describe it to me.  Does this student have a favorite color or does this student seem to have no color or pattern preference?



5.  Describe this student’s strengths?



6.  Describe appearance of eyes and any unusual visual behaviors.



7.  Does this student use his/her vision differently on different days or at different times of the day?



8.  Do you notice that your student is more visually attracted to toys/objects that are still or have movement?    For example, does this student visually attend to moving ceiling fans or toys that have movement properties more than you would expect?



9.  Does this student ever have a delay in visual attending of a few seconds (or even up to 30 or 60 seconds)?



10.  Do you notice that this student more often visually alerts to objects/toys when presented on one side more than the other?   Does your child tilt or turn his/her head when visually observing a target?



11.  Do you notice this student using his/her vision more in a room that is quiet, with no auditory distractions or is there more visual attending in a noisy room?


12.  Will this student visually attend to your face and if so, how far away are you from the student?



13.  Will this student observe picture books and if so, describe what the pictures look like in their favorite book (i.e. black and white simple pictures, colored pictures, or complex pictures).



14.  Is this student attracted to lights or sunny windows?  Describe the setting/lighting if so.  How far away are the lights/window, what color are the lights, and can the student’s attention be redirected after he/she has been looking at lights/windows?



15.  Does this student demonstrate attending behavior when people first enter a room without making any sound?  If so, how far away are they when the student demonstrates recognition or alerts to their presence?



16.  When this student drops something, does he/she try to locate it and if so, how does your child do this?



17.  Do you notice this student visually attending to objects or people at a distance of greater than 10 feet when there is no sound to alert them?



18.  If given an unfamiliar toy, would this student respond to it or would he/she only respond to familiar toys/targets?



19.  Are there any other concerns you have with regard to this student’s vision that we have not discussed?  Are there any specific settings that you would like me to see this student in?



Created By Diane Sheline, CTVI, CLVT



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