Vision Impairment Special Education Referral
Student Information
Student Name
Date of Birth
Grade
School
Teacher
Referring Person
Reason for Referral
Describe the primary reason for referral
Observed Vision Concerns
Please describe observed concerns related to vision
Classroom Impact
How has vision affected educational performance, participation, or access?
Accommodations/Interventions Tried
List classroom strategies or accommodations already provided
Additional Comments