Vision

EVS Forms

Contact David Cohen DCohen2@schools.nyc.gov for more information.

Educational Vision Services Forms

Title	Size
Provider Schedule	112kb
Monthly Attendance Record	76kb
Supply Request Form	28kb
E-12S Eye Report Form	40kb
Book Order Form	40kb
APH Quota Ordering Form	32kb
Letter for Principal to request Book for Brailling or Enlarging	48kb
Functional Vision Assessment Form	72kb
EVS Keyboarding Skills Chart	64kb
EVS Keyboarding Skills Assessment	64kb
O&M Screening Form	36kb
EVS Assistive Technology Evaluation Instructions	380kb
EVS Assistive Technology Referral Form	2.5mb
Legally Blind Form	144kb
Eye Report Request Letter	44kb
Parent/Teacher Conference Attendance Report	24kb
Offsite Equipment Form – Staff	432kb
Offsite Equipment Form - Student	308kb
EVS Reimbursment Form	16kb

Orientation and Mobility Services Forms

Title	Size
Instruction Consent Form	168kb
Evaluation Consent Form	168kb
Procedures for Requesting an O&M Evaluation	232kb
Preparing and Submitting O&M Evaluation Reports	152kb
O&M Screening Form	36kb
Extent of Service Needs and Recommendations Guidelines	44kb
Dynamic Functional Vision Assessment Coversheet	40kb
EVS Dynamic Functional Vision Assessment	40kb
Log Book Cover Page	64kb
Student Information Page	124kb
Safety Cards	44kb
Log of Student Lessons	64kb
Independent Travel Agreement	104kb
Indoor Travel Clearance Procedures Memo	36kb
Indoor Independent Travel Checklist	28kb
Parent Consent for Indoor Independent Travel Form	40kb
Requirements for Route Travel Clearance	84kb
Outdoor Travel Clearance Procedures Memo	36kb
Outdoor Independent Travel Checklist	68kb
Parent Consent for Outdoor Independent Travel Form	40kb
EVS Referral to Travel Training	64kb

District 75 | 400 First Avenue, New York, NY 10010 | (212) 802-1500 | Contact