Impact of Vision Impairment for Children (IVI-C) Form
* Required
© Centre for Eye Research Australia 2010
www.cera.org.au
Student First Name
*
Your answer
Student Last Name
*
Your answer
Date of Birth
MM
/
DD
/
YYYY
Current TVI
Choose
NA
Susan Barber
*Katrina Bennet
Christy Bowen
Joan Brodbeck
Angie Brown
*Meaghan Burr
Karen Carlile
Teri Chaney
Abigail Chappell
Annalee Crotinger
Alyssa Cruickshank
Naomi Danso
Carri Davis
Melissa Day
Jennifer DeHoet
Jayann Donker
Leslie English
*Stephanie Frank
Nancy Gieske
Cindy Grove
Anne Gurss
Heather Hagstrom
Christie Hatton
Rachel Haydon
Debbie Heeren
Jeri Hile
Noda Hileman
Lana Hittle
Menely Hogan
*Carady Holguin
Kelli Holthaus
Karen Hooser
Myra Horton
Kylie Janssen
Leslie Johnson
*Krystal Karschimkus
Carolyn Kerstetter
Penny Kimberling
Liz Lawlor
Teresa Lehr
Susan Levra-Wallace
Jennifer Luna
Chris Mancillas
Nancy Mann
Brenda Mattivi
Sabrina McAdoo
Kim McCall
Chris Mickelson
Laura Mitchell
Debbie Moody
Theresa Niblock
Jeanine Oliver
Shari Oren
Heather Pedersen
Molly Reardon
Andrea Regier
Vanessa Rosalan
*Kindra Rowley
Debbie Sargent
*Tim Schierbeck
Aundrayah Shermer
*Shobra Signh
Joli Skaer
Brandi Smith
susan Threlnen
Charina Tunget
Tammy Warford
Jennifer Weber
Instructions
I’m going to read some questions to you.
The questions are about you, your school, your family and others around you.
Please say which answer best describes what you do and feel most of the time. There are no right or wrong answers.
Please answer the questions for yourself – your family is important but we don’t want their answers, we want yours.
Please answer with one of the responses that I read out to you.
Some things you won’t do because you are too young or for other reasons. For these questions just answer, ‘no, for other reasons’.
The questions are all about how things are for you because of your eyesight. (This statement should be restated, as needed, before asking question[s]).
Answers to Questions are. almost always; sometimes; almost never; no, for other reasons.
Thank you, I’ll read the questions now.
Do you find it difficult to go downstairs or to step off the footpath?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Are you confident to make your own way to school?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Are you confident to use public transport (such as buses, trains, ferries) by yourself?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Are you confident in places you don't know?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Are you confident that you can move around safely in places you don't know in the daytime?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Are you confident that you can move around safely in places you don't know at night-time?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Can you find your friends in the playground at lunch and play time?
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Almost Always
Sometimes
Almost Never
No, for other reasons
When you are in a room, can you recognize people you know before they speak to you?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Can you take part in games or sports that you want to play with your friends?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do you get the chance to go to activities other than sport (such as social groups)?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Has your eyesight stopped you from doing things you want to do?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Do other students help you when you ask for help?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do other students help you to join in with them?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do you find it hard to join in with other students?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do you get frustrated?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do other students understand your special needs?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do your teachers understand your special needs?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
In the classroom, do you get all the same information as the other students?
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Almost Always
Sometimes
Almost Never
No, for other reasons
Do you get all the information at the same time as other students?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Do you get enough time in school to complete the work set by the teacher?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
When you are in the classroom, are you confident about asking for help you need?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
When you ask for help, do people understand how much help you need?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Do people tell you that you can't do the things that you want to do?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
Do people stop you from doing the things you want to do?
*
Almost Always
Sometimes
Almost Never
No, for other reasons
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