Iowa Educational Services for the
Blind and Visually Impaired
PARENT INTERVIEW
FUNCTIONAL VISION – LEARNING MEDIA ASSESSMENTS (AGES 5-21)
SECTION 1 – GENERAL STUDENT INFORMATION
1. Student Name:
2. Date of Birth:
3. Parent(s) Interviewed:
4. Date:
5. Examiner:
SECTION 2 – MOBILITY/TRAVEL
1. Does your child ever have problems getting around in the dark? YES or NO
2. If so, explain:
3. Does your child have problems with bright lights? YES or NO
4. How does your child adjust to different lighting?
5. Does your child have trouble getting around in unfamiliar environments? YES or NO
6. Explain:
7. Does your child travel independently outdoors? YES or NO
8. Explain:
9. What sports does your child engage in for recreational purposes?
SECTION 3 – ACADEMICS
1. What subject area do they have the most difficulty in at school?
2. Does your child have difficulty completing homework: YES or NO
Parent Interview FVA-LMA (Ages 5-21).docx
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a. If yes, explain why you think this is so:
3. Does your child complete their homework? YES or NO
4. Are you pleased with your child’s educational progress? YES or NO
a. Explain:
SECTION 4 – VISUAL RESPONSE
1. Does your child watch television? YES or NO
2. How far away from the screen does your child sit?
3. Does your child like to play computer or video games? YES or NO
4. How far away from the screen does your child sit?
5. Does your child like to play with books or read? YES or NO
6. What size pictures and font do they enjoy reading?
7. Does the glare on a page seem to bother your child? YES or NO
8. If your child has been diagnosed as being totally blind, do you think that he/she sees? YES or NO
a. Explain:
9. Do you notice your child bringing things closer to look at them? YES or NO
10. How close does your child generally hold small objects?
11. Does your child have trouble finding food or knowing what’s on their plate? YES or NO
12. Do you ever notice your child turning their head to look at objects? YES or NO
a. If yes, which way do they turn their head?
13. Do you feel that there are areas of your son’s/daughter’s visual field, which are more effective than
others? YES or NO
a. Explain:
14. Does your child experience visual fatigue? YES or NO
15. How long can your child read before experiencing visual fatigue?
16. Is your child able to see things outside the car window? YES or NO
Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998
and from Heartland AEA 11 — Vision Department - 2003
Parent Interview FVA-LMA (Ages 5-21).docx
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17. Is your child able to see when you enter a room? YES or NO
18. Can your child recognize friends or family members from across a room? YES or NO
SECTION 5 – ACTIVITIES OF DAILY LIVING
1. Is your child able to perform activities of daily living at a level equal to other children their age? YES or
NO
2. If no, what activities give him/her the most trouble?
3. Personal Body Care
4. Self-Help
5. Social Habits
6. Home Assistance
7. Recreation/Leisure Skills
8. Moving in the near environment
9. Other:
SECTION 6 -- POST-SECONDARY PLANS (14 YEARS AND OLDER)
1. Has a referral been made to Iowa Department for the Blind? YES or NO
2. Describe post-secondary expectations for learning.
3. Describe post-secondary expectations for living.
4. Describe post-secondary expectations for working.
SECTION 7 – SOCIAL
1. Does your child have friends? YES or NO
2. Does your child interact with other children in about the same way as other children their age? YES or
NO
a. Explain:
Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998
and from Heartland AEA 11 — Vision Department - 2003
Parent Interview FVA-LMA (Ages 5-21).docx
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SECTION 8 – PERSONALITY
1. Are there activities that your child particularly enjoys?
2. Are there activities that your child avoids?
3. What things does your child like to listen to?
Adapted from Dr. Dixie Mercer — Texas School for the Blind and Visually Impaired, 1998
and from Heartland AEA 11 — Vision Department - 2003
Parent Interview FVA-LMA (Ages 5-21).docx
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