Wisconsin Department of Public Instruction INSTRUCTIONS: This form is provided to assist school district ELIGIBILITY CHECKLIST individualized education program (IEP) teams in determining if a student
VISUAL IMPAIRMENT appropriately can be determined to have an impairment under Chapter 115, Wis. Stats., and the eligibility criteria established in PI 11.36, Wis. Admin.
ELG-VIS-001 (Rev. 07-09) Code. The IEP team should complete this form to document determination of eligibility for special education services and keep it on file with the
This form is provided for local use only. student record.
Student Name Date of Eligibility Determination
Visual impairment means even after correction a child’s visual functioning significantly adversely affects his or her educational performance. The IEP team may identify a child as having a visual impairment after all of the following events occur:
Section I. FUNCTIONAL VISION EVALUATION (All must be checked Yes.)
A certified teacher of the visually impaired conducted a functional vision evaluation, including:
Yes No Review of medical information, Yes No Formal/informal tests and
Yes No Educational implications and curricular needs.
Explain or reference data finding:
Section II. OPHTHALMOLOGIST/OPTOMETRIST EVALUATION
(At least one must be checked Yes.)
An ophthalmologist or optometrist finds at least one of the following (check all that apply):
Yes No Central visual acuity of 20/70 or less in the better eye after conventional correction
Yes No Reduced visual field to 50 degrees or less in the better eye
Yes No Other ocular pathologies that are permanent and irremediable Yes No Cortical visual impairment
Yes No A degenerative condition that is likely to result in a significant loss of vision in the future Explain or reference data used to support findings:
Section III. ORIENTATION AND MOBILITY NEEDS
Yes No Orientation and mobility needs were evaluated to determine if there are related mobility needs in home, school, or community environments.
The evaluation was conducted by:
An orientation and mobility specialist, or
A teacher of the visually impaired in conjunction with an orientation and mobility specialist. Explain or reference data used to support findings: