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Template for Functional Vision Assessment (FVA) for Students with CVI

This 8-page template for Functional Vision Assessment (FVA) for students with CVI can be individualized for each child. It includes some general information and sections that are helpful in organizing information from the CVI Range assessment.

This 8-page form is offered as a template and should be individualized, based on the results of the CVI Range Assessment and additional student needs.  All highlighted areas should be replaced with your own information.

This form includes the following sections:

  1. Background/Process
  2. Results

    • Color preferences
    • Need for movement
    • Visual latency
    • Visual field preferences
    • Difficulty with visual complexity

      • target/object
      • visual array
      • multi-sensory
      • faces
    • Need for/attraction to light
    • Difficulty with visual novelty
    • Difficulty with visually-guided reach
  3. Summary of Results
  4. Recommendations

    1. Material adaptations/adaptations to presentation of materials (by Phase and Characteristic)
    2. Planning adaptations in activities
    3. CVI Schedule
    4. Training for Educational Team Members
    5. Additional resources
  5. Summary

Template for Functional Vision Assessment for Students with CVI

Collage of Template for FVA for CVI

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