Workplace Assessment – Adults with Visual Impairment

This assessment is completed by a Teacher of Students with Visual Impairments (TVI) / Vision Rehabilitation Specialist in collaboration with the employee. The purpose is to identify strengths, challenges, and workplace accommodation needs so that the employee can perform their work safely, efficiently, and as independently as possible.

Section 1 – About You and Your Work Situation

1. Name ^*

2. Date ^*mm/dd/yyyy

3. Workplace

4. Job Title

5. Department

6. Employment Status Full-time Part-time Temporary Supported/Adapted Employment Other

7. What is most important to you in your workday?Select all that apply. Perform my work tasks successfully Work more independently Reduce visual or physical strain Keep my job Participate in meetings Use my computer more efficiently Read documents more easily Move around the workplace more safely Other

8. What would you like help with through this assessment?

9. Eye diagnosis / Visual diagnosis (if known)

10. How do you experience your vision?Select all that apply. Blurred vision Reduced central vision Reduced peripheral vision Sensitive to glare Difficulty seeing contrasts Poor vision in low light Difficulty seeing at near distance Difficulty seeing at far distance Double vision Vision fluctuates Eye fatigue / Visual fatigue Other

Section 2 – Job Tasks

11. Which work tasks do you perform? Computer work Customer service Telephone work Writing Reading Document management Teaching Meetings Practical work Warehouse work Production Other

12. Which work tasks do you perform well?

13. Which work tasks are the most challenging?

Section 3 – Work Environment: Lighting and Contrast

14. How is the lighting in your workplace? Adequate Too bright Too dim Causes glare

15. Can the lighting be adjusted? Yes Partly No

16. Where is the lighting challenging? Office Meeting room Corridor Cafeteria Warehouse Stairs Entrance / Outdoors Other

17. Are there good visual contrasts in the following areas?

	Yes	Partly	No
Doors
Stairs
Handrails
Light switches
Signs
Restrooms
Cafeteria

Section 4 – Workplace Labelling

18. Are the following labelled? Office door Drawers Shelves Filing cabinets Equipment Printer Coffee machine Microwave Elevator Room numbers Meeting rooms Other

19. What type of labelling is used? Braille Tactile labels High-contrast labels Large print No labelling

20. What should be labelled more clearly?

Section 5 – Assistive Technology

Optical Devices Hand magnifier Stand magnifier Monocular / Telescope Filter glasses

Electronic Devices Electronic magnifier CCTV / Video magnifier OCR reader Document camera

Computer Software ZoomText SuperNova Fusion JAWS NVDA Windows Magnifier VoiceOver (Mac) Narrator

Mobile Devices VoiceOver (iPhone) TalkBack (Android) Screen Magnification Dictation Seeing AI Envision Be My Eyes Google Lookout

Ergonomic Equipment External monitor Large monitor Monitor arm Reading stand Document holder Ergonomic chair Height-adjustable desk

21. Have you received training in using your assistive technology? Yes Partly No

22. Do you need additional or improved assistive technology?

Section 6 – Digital Work Tasks

23. Can you perform the following digital tasks?

	Yes	Partly	No
Write documents
Read email
Use Teams / Video meetings
Use Outlook
Use Word
Use Excel
Use internal systems
Write reports
Search for information online

Section 7 – Orientation in the Workplace

24. Do you have difficulty locating… Entrance Your office Meeting room Elevator Restroom Cafeteria Stairs Emergency exits Parking area

25. Do you need… High-contrast markings Guiding lines Tactile signage Orientation training Orientation and Mobility (O&M) training Other

Section 8 – Social Participation

26. Does your visual impairment affect… Meetings Collaboration with colleagues Social breaks Courses and training Professional development days Online meetings Presentations Other

27. Are your colleagues and manager aware of your visual impairment? Yes, everyone knows Some people know No

28. Do you feel included in your workplace? Yes Partly No

Section 9 – Workload and Energy

29. How fatigued do you become during the workday? Not fatigued Slightly fatigued Very fatigued Extremely fatigued

30. What is most demanding? Lighting Screen use Reading Moving around Meetings Noise Work pace Other

31. Do you need additional breaks or adjustments to your work schedule? Yes Somewhat No

32. Have you been in contact with your country’s vocational rehabilitation or workplace accommodation services regarding workplace adaptations? Yes No No, but I would like to

Section 10 – Vision Specialist’s Observations

33. ObservationsCheck all that apply. Working posture Working distance Screen positioning Lighting needs Contrast needs Reading strategies Use of assistive technology Use of accessibility features Workplace orientation Indoor mobility Need for training Need for additional assistive technology Need for workplace accommodations Need for collaboration with vocational rehabilitation services

34. Additional observation notes

35. Observed strengths and coping strategies

36. Recommendations for further referral

Section 11 – Summary and Action Plan

37. Main challenges

38. Strengths and Resources

39. Action Plan

Action	Responsible Person	Deadline	Priority

Example: Within 2 weeks

40. Date of the next evaluationmm/dd/yyyy

Your email address (optional – to receive a copy of this form)