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Functional vision assessment template

Functional vision assessment template 2026

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The document is a Functional Vision Assessment Checklist designed to evaluate the visual capabilities and needs of students with visual impairments. It includes sections for recording personal information, the nature and extent of the visual impairment, educational implications, access to instructional materials, vision-related behaviors, social/emotional factors, and suggested recommendations for instructional modifications and specialized materials. The checklist aims to provide a comprehensive overview of the student's functional vision to inform educational strategies and interventions.

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Click ‘Get Form’ to open the functional vision assessment template in the editor.
Begin by entering the date, student’s name, age, grade, and school/placement in the designated fields at the top of the form.
In the 'Reason for assessment' section, select from options such as 'New referral' or 'Triennial review', and provide any additional information if necessary.
Fill out details regarding the nature and extent of visual impairment, including diagnosis and prognosis. Be sure to specify acuity for near and distance vision.
Complete sections on educational implications and general learning abilities by providing insights into how the visual impairment affects learning.
Continue through each section methodically, detailing access to instructional materials and instructional formats that can be seen.
Finally, review your entries for accuracy before saving or sharing the completed assessment using our platform's features.

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How to assess visual function?

Typical visual function tests assess factors such as visual acuity, contrast sensitivity, color, depth, and motion perception. These properties each represent an aspect of visual function and may impact an individuals level of functional vision.

What is a functional assessment of the eye?

The functional vision assessment (FVA) is for children with low vision. It is an assessment of how a child uses their vision in everyday life, so it is usually not done with children who are totally blind or have light perception only.

How do you assess visual perception?

The Motor Free Visual Perception Test (MFVPT)45: This is a multiple-choice test that requires the individual to point to an appropriate response. The test contains items in five categories of visual perception: spatial relationships, visual discrimination, figure-ground, visual closure, and visual memory.

What is the functional assessment tool for vision impairment?

The Functional Vision Assessment (FVA) is an assessment of how a learner using their vision for everyday activities. A teacher of students with visual impairments (TVI) will perform the assessment through a variety of tests, observations, and interviews with parents, teachers, and the learner.

How is visual ability measured?

Visual acuity test. The visual acuity test is used to determine the smallest letters you can read on a standardized chart (Snellen chart) or a card held 20 feet (6 meters) away.

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What is included in a functional vision assessment?

Functional Visual Acuity: Assesses visual acuity (visual clarity, sharpness of vision) for near (reading, writing, drawing, etc), mid-range (alternative communication device, computer, etc.), and distance vision. Color Vision: Assesses for color vision deficiency, which can make early learning more challenging.

What are the 4 levels of visual function?

There are four levels of visual function, ing to the International Classification of Diseases -10 (Update and Revision 2006): normal vision moderate visual impairment severe visual impairment blindness.