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Informant ______________________________________

Position _______________________________________

Child’s Name ____________________________________

Age _______________    Date of Interview _______________

Interviewer _____________________________

1. Please describe this child's visual impairment:

  • What have the doctors, ophthalmologist, and/or optometrist told you about the child's diagnoses?

  • What has the family told you about this child’s visual impairment?

  • (For children with low vision) how does this child use his or her vision in different activities?



Does the child respond to light? Sunlight? Flashlight? How does he or she behave in response to the light?


Have you noticed your child responding to persons or objects? (What about their size, color, distance, location) How do you know when the child is looking at something? Does the child have a preferred visual field?

Have you observed if the child likes any particular color? When you have observed this? How does he or she respond to this color?

2. Please describe the child’s hearing loss:

  • What have the doctors and audiologist told you about the child’s diagnosis?

  • What has the family told you about the child’s hearing loss?

  • (For children with some hearing) How does this child use hearing in different situations? What sounds does this child respond to? How loud do they need to be?



Does he respond to his or her name or any specific spoken words?


How does the child respond? For example does he or she smile, blink his eyes, start vocalizing, stop vocalizing, move any part of the body? Does he turn towards the sound source?

Does this child seem to have a better ear? (Better responses if the sound is presented on the left or right side?)

3. Please describe the child’s other special needs.


4. What are the child's favorite people, objects, and activities? Why do you think they are favorites?




About each preferred person:
Why do you think he or she likes this person? How does this child express this preference? Does this child do something different with this person that he or she doesn’t do with other people?


About each preferred object:
Why do you think he or she likes this object? What it is made of? How does it feel (texture)? How big is it? What’s its shape? What does this child do with this object?
What characteristics of objects do you think this child really likes?


About each preferred activity:
Why do you think he or she likes this activity? Which characteristics of activities do you think this child really likes?

5. What people, objects, and activities does the child dislike? Why?




About each person:
Why do you think the child dislikes this person? How does the child express dislike?


About each object:
Why do you think the child dislikes this object? Is it the texture? What it is made of? What is the child supposed to do with that object?


About each activity:
Is there any activity that the child doesn’t like that we haven’t mentioned yet? What is it about certain activities that doesn’t appeal to this child?

6. How does the child handle objects and use the sense of touch in different situations and activities?

  • What is the child usually doing with his or her hands? For example, shakes them or puts them in the mouth? Holds into something? Keep them by his or her side.

  • Does the child use one hand or both hands to pick up and handle an object?

  • What does the child usually do with objects he can handle independently? For example, how does he or she manipulate it?

  • How do you encourage your child to handle and examine objects using touch?

7. How does the child interact tactilely with you, other family members, and friends?

For example: does the child like to touch people’s faces, or their hands? Is it common for this child to touch you or other people? When the child reaches out and touches you or other people, why do think he or she does it and in which situations?

8. How do you and other people (teachers, peers, etc.) interact tactilely with the child? Which parts of the child’s body do you touch or move? Why? Have you found any particular area of his or her body that this child prefers you to touch? Is there an area of the body that the child dislikes being touched? Does this child like firm touch or light touch? Show me how you might help this child.

9. How does this child communicate needs, desires, and other ideas?

For example, body movements, signs, or vocalization? How does he or she do it?

10. How much time does this child take to respond when you or others communicate with him or her?

11. How do you communicate with him or her? For example: do you use objects or other cues? Do you use tactile signs? Do you talk to him or her?

12. When is the child most attentive and responsive? At what times? With what people and for what activities?