EDUCATOR'S CHECKLIST
             OBSERVABLE CLUES TO
         CLASSROOM VISION PROBLEMS

Student's Name ______________       Date__________

1 .  APPEARANCE OF EYES:

           One eye turns in or out at any time  ______
           Reddened eyes or lids ______
           Eyes tear excessively  ______
           Encrusted eyelids  ______
           Frequent styes on lids  ______

2.  COMPLAINTS WHEN USING EYES AT DESK:

           Headaches in forehead or temples ______
           Burning or itching after reading or desk work  ______
           Nausea or dizziness ______
           Print blurs after reading a short time ______

3.  BEHAVIORAL SIGNS OF VISUAL PROBLEMS:

     A.  Eye Movement Abilities

          (Ocular Motility)
          Head turns as reads across page ______
          Loses place often during reading ______
          Needs finger or marker to keep place ______
          Displays short attention span in reading or copying ______
          Too frequently omits words ______
          Repeatedly omits "small" words ______
          Writes up or down hill on paper ______
          Rereads or skips lines unknowingly ______
          Orients drawings poorly on page ______

   B.   Eye Teaming Abilities
          (Binocularity)

         Complains of seeing double (diplopia) ______
          Repeats letters within words ______
          Omits letters, numbers or phrases ______
          Misaligns digits in number columns ______
          Squints, closes or covers one eye ______
          Tilts head extremely while working at desk ______
          Consistently shows gross postural deviations at all desk activities ______

   C.   Eye-Hand Coordination Abilities

          Must feel of things to assist in any interpretation required ______
          Eyes not used to "steer" hand movements (extreme lack of orientation,
          placement of words or drawings on page)       ______
          Writes crookedly, poorly spaced: cannot stay on ruled lines ______
          Misaligns both horizontal and vertical series of numbers ______
          Uses his hand or fingers to keep his place on the page ______
          Uses other hand as "spacer" to control spacing and alignment on page ______
          Repeatedly confuses left-right directions ______


D.     Visual Form Perception
         (Visual Comparison, Visual Imagery, Visualization)

         Mistakes words with same or similar beginnings ______
         Fails to recognize same word in next sentence ______
         Reverses letters and/or words in writing and copying ______
         Confuses likenesses and minor differences ______
         Confuses same word in same sentence ______
         Repeatedly confuses similar beginnings and endings of words ______
         Fails to visualize what is read either silently or orally ______
         Whispers to self for reinforcement while reading silently ______
         Returns to "drawing with fingers" to decide likes and differences ______

E.    Refractive Status
        (Nearsightedness, Farsightedness, Focus Problems, etc.)

        Comprehension reduces as reading continued; loses interest too quickly ______
        Mispronounces similar words as continues reading ______
        Blinks excessively at desk tasks and/or reading; not elsewhere ______
        Holds book too closely; face too close to desk surface ______
        Avoids all possible near-centered tasks ______
        Complains of discomfort in tasks that demand visual interpretation ______
        Closes or covers one eye when reading or doing desk work ______
        Makes errors in copying from chalkboard to paper on desk ______
        Makes errors in copying from reference book to notebook ______
        Squints to see chalkboard, or requests to move nearer ______
        Rubs eyes during or after short periods of visual activity ______
        Fatigues easily; blinks to make chalkboard clear up after desk task ______

        OBSERVER'S SUGGESTIONS:

Signed (Print) ________________________________________
(Encircle) Teacher, Nurse, Remedial Teacher, Psychologist, Vision Consultant, Other
Phone __________________________________________________________
Address_______________________________________________________

Copyright 1985 by
Optometric Extension Program Foundation, Inc.
2912 South Daimler, Santa Ana, CA 92705-5811
- B -

I'd like to say a special thanks to the Optometric Extension Program Foundation, Inc.
for allowing us to use the materials for "Educator's Guide to Classroom Vision Problems"
as well as the "Educator's Checklist."

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