"Low Vision Evaluation (Lve) Report for Students in Georgia Schools" - Georgia (United States)

Low Vision Evaluation (Lve) Report for Students in Georgia Schools is a legal document that was released by the Georgia Department of Education - a government authority operating within Georgia (United States).

Form Details:

  • The latest edition currently provided by the Georgia Department of Education;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Georgia Department of Education.

ADVERTISEMENT
ADVERTISEMENT

Download "Low Vision Evaluation (Lve) Report for Students in Georgia Schools" - Georgia (United States)

1376 times
Rate (4.5 / 5) 83 votes
LOW VISION EVALUATION (LVE) REPORT
FOR STUDENTS IN GEORGIA SCHOOLS
Items with an asterisk (*) are considered the minimal components of a Clinical Low Vision
Evaluation Report for educational purposes.
*BACKGROUND INFORMATION
Student’s name
Date of evaluation
School system
DOB /age
Low vision clinic name
Low vision therapist (If attending)
Low vision optometrist/clinician’s name
*MEDICAL HISTORY
Date of current medical eye examination
Name of clinician
Check one:
MD
OD
Reported ocular diagnosis from medical eye examination
Previous LVE
Yes
No.
If yes ,date.
*Please attach current medical eye report
and most recent LVE report
(Mandatory)
(if applicable).
Additional disabilities/medical problems:
This model low vision evaluation form was developed by the Georgia Department of Education to assist low vision optometrist conducting low
vision evaluations (LVE’s) with a format to report information needed by local school systems for vision impaired eligibility and educational
planning purposes. These forms may be reproduced as needed by low vision clinics and educational personnel.
Page 1
LOW VISION EVALUATION (LVE) REPORT
FOR STUDENTS IN GEORGIA SCHOOLS
Items with an asterisk (*) are considered the minimal components of a Clinical Low Vision
Evaluation Report for educational purposes.
*BACKGROUND INFORMATION
Student’s name
Date of evaluation
School system
DOB /age
Low vision clinic name
Low vision therapist (If attending)
Low vision optometrist/clinician’s name
*MEDICAL HISTORY
Date of current medical eye examination
Name of clinician
Check one:
MD
OD
Reported ocular diagnosis from medical eye examination
Previous LVE
Yes
No.
If yes ,date.
*Please attach current medical eye report
and most recent LVE report
(Mandatory)
(if applicable).
Additional disabilities/medical problems:
This model low vision evaluation form was developed by the Georgia Department of Education to assist low vision optometrist conducting low
vision evaluations (LVE’s) with a format to report information needed by local school systems for vision impaired eligibility and educational
planning purposes. These forms may be reproduced as needed by low vision clinics and educational personnel.
Page 1
*VISUAL ACUITIES:
Distance
Intermediate
Near
(20’ or less as determined
(18”-36”)(Please indicate at
(Up to 16”)(Please indicate at
by clinician)(Please indicate
what distance).
what distance).
at what distance).
Without
With
Without
With
Without
With
Correction
Correction
Correction
Correction
Correction
correction
O.D.
O.S.
O.U.
*Visual Fields: (Check one).
Interpretation of formal visual fields testing from primary eye care physician by low vision
optometrist:
Results:
OR
Determination of confrontation visual fields by low vision optometrist:
Results:
COLOR VISION SCREENING (Check all that apply)
Farnsworth D-15
Farnsworth D-15 jumbo
Farnsworth D-15 matching
Ishihara color plates
Other color vision screening(Please specify)
This model low vision evaluation form was developed by the Georgia Department of Education to assist low vision optometrist conducting low
vision evaluations (LVE’s) with a format to report information needed by local school systems for vision impaired eligibility and educational
planning purposes. These forms may be reproduced as needed by low vision clinics and educational personnel.
Page 2
Results:
Refractive Evaluation
Sphere
Cylinder
Axis
Prism
Add
Right eye (OD)
Left eye (OS)
*Binocularity (Check one)
Binocular
Monocular
Bi-ocular (Each eye is working independent of the other one).
Preferred eye
*Contrast Sensitivity
Type of sensitivity:
Degree of sensitivity:
Illumination needs:
Glare issues:
This model low vision evaluation form was developed by the Georgia Department of Education to assist low vision optometrist conducting low
vision evaluations (LVE’s) with a format to report information needed by local school systems for vision impaired eligibility and educational
planning purposes. These forms may be reproduced as needed by low vision clinics and educational personnel.
Page 3
*Contrast Sensitivity (Continued)
Color/background contrast needs:
General impressions:
Concerns of student/family and recommendations:
Activity restrictions (if any):
Eye safety recommendations:
Additional evaluations/tests needed:
Devices recommended to access instruction in appropriate development sequence:
NEAR
Optical:
Non-optical:
Electronic/software:
INTERMEDIATE
Optical:
Non-optical:
Electronic/software:
DISTANCE
Optical:
Non-optical:
Electronic/software:
Lighting and glare control:
Seating recommendations:
Recommendations for binocularity issues (if any):
This model low vision evaluation form was developed by the Georgia Department of Education to assist low vision optometrist conducting low
vision evaluations (LVE’s) with a format to report information needed by local school systems for vision impaired eligibility and educational
planning purposes. These forms may be reproduced as needed by low vision clinics and educational personnel.
Page 4
Recommendations for use of devices for specific tasks needed to access instruction:
Recommendations for future low vision evaluations:
__________________________________________
___________________________
Low Vision Optometrist Signature
Date of LVE
__________________________________________
Low Vision Therapist Signature
This model low vision evaluation form was developed by the Georgia Department of Education to assist low vision optometrist conducting low
vision evaluations (LVE’s) with a format to report information needed by local school systems for vision impaired eligibility and educational
planning purposes. These forms may be reproduced as needed by low vision clinics and educational personnel.
Page 5
Page of 5