Home Environment Assessment – Children and Young People with Visual Impairment

Section 1: About the Child and Family

1. Child’s Name ^*

2. Age

3. Eye Diagnosis / Visual Diagnosis

4. Date of Assessment ^*mm/dd/yyyy

7. Does the child have siblings? Yes No

8. Which other adults are involved in the child’s daily life?Support worker, relatives, etc.

Section 2: Home Environment

9. Type of home Apartment Townhouse Detached house Other

10. Does the child have their own bedroom? Yes No

11. Are there stairs inside the home? Yes No

12. Are the stairs marked with contrasting colors? Yes No Not applicable

13. How are the lighting conditions at home?

14. Is there glare from windows or lighting? Yes No Sometimes

15. Can the lighting be adjusted? Yes No Partly

Section 3: Assistive Technology at Home

17. Are the assistive devices used regularly? Yes, every day Sometimes Rarely Never

18. Is the child motivated to use the assistive devices? Yes Partly No

19. Have the parent(s)/guardian(s) received training in the use of the assistive devices? Yes No Partly

20. Is there a need for new assistive devices? Yes No Don’t know

Section 4: Digital Devices and Screen Use

21. Digital devices the child uses Smartphone Tablet PC/Mac Other

22. Are accessibility features used?VoiceOver, TalkBack, text size, etc. Yes No Don’t know

23. Does screen use work well with the child’s visual impairment? Yes No Partly

24. Are Screen Time limits or other restrictions used? Yes No

Section 5: Daily Living Skills and Independence

25. Can the child dress independently? Yes, independently With a little help Needs a lot of assistance

26. Can the child eat independently? Yes Partly No

27. Can the child manage personal hygiene independently? Yes Partly No

28. Can the child help with simple household tasks? Yes Partly No

29. Does the child sleep well? Yes Sometimes has sleep difficulties No

Section 6: Play, Leisure and Friends

30. What does the child enjoy doing in their free time?

31. Does the child participate in organized leisure activities?Sports, arts, music groups, etc. Yes No Has tried but stopped

32. Does the child have friends in the local community? Yes A few No

33. Does the child take part in playdates? Yes Rarely No

34. What limits the child’s participation in play and leisure activities?

Section 7: Outdoor Mobility and Orientation

35. Can the child walk to school independently? Yes No With assistance

36. Can the child use public transportation? Yes No With assistance

37. Is the traffic environment near the home safe? Yes No Partly

38. Is there a need for Orientation and Mobility (O&M) training? Yes No Already receiving training

Section 8: Mental Health and Well-being

39. Is the child generally happy in everyday life? Yes Partly No

40. Does the child talk openly about their visual impairment? Yes A little No

41. Does the child show signs of frustration or grief related to their vision? Yes Sometimes No

42. Is there a need for psychological support or counseling? Yes No Don’t know

43. Is the family familiar with organizations for people with visual impairment?Examples: National Federation of the Blind, family support organizations, etc. Yes No

Section 9: Parents’ Situation and Resources

44. How do the parent(s)/guardian(s) experience everyday life with the child’s visual impairment?

45. Do the parent(s)/guardian(s) receive sufficient information from the school and healthcare services? Yes Partly No

46. Are respite care services known or being used? Yes No Not applicable

47. Does the family have contact with other families in similar situations? Yes No

48. What kind of support would the parent(s)/guardian(s) like to receive?

Section 10: Summary and Action Plan

49. What is working well at home?

50. What are the biggest challenges?

51. What should be prioritized moving forward?

52. Key findings from the assessment

53. Recommended interventions

54. Person responsible for follow-up

55. Date of the next evaluationmm/dd/yyyy

56. Additional comments