REGISTRATION OF STUDENT WHO IS BLIND/VISUALLY IMPAIRED Colorado Department of Education (CDE) & Colorado Instructional Materials Center (CIMC) COUNT 1-STATEWIDE B/VI COUNT: All students birth – 21 receiving vision services 1.STUDENT NAME – LAST, FIRST: 2. SASID # (10 DIGIT): 3. DATE OF BIRTH: 4. DISTRICT OF RESIDENCE(*may be different than District student is attending): 5. DISTRICT OF ATTENDANCE: 6. CURRENT GRADE LEVEL: 7. PRIMARY LANGUAGE OF INSTRUCTIONAL MATERIALS: 8. PRIMARY CURRENT READING MEDIA: 9. PROJECTED READING MEDIA: 10. REGISTRATION DATE: 11. PRIMARY DISABILITY: SECONDARY DISABILITY: 12. VISION ACUITY WITH CORRECTION: RIGHT EYE (OD) LEFT EYE (OS) PERIPHERAL FIELD 20 degrees OR LESS: Yes or No 13. DIAGNOSIS: 14. IS THIS STUDENT REGISTERED IN COLORADO DEAFBLIND CENSUS? YES or NO 15. TACTILE LEARNER: YES or NO BRAILLE LEARNER: YES or NO BRAILLE USER: YES or NO 16. STATE ASSESSMENT: General CMAS/PARCC? Alternate CoALT/DLM? or N/A? 17. PLEASE CHECK THE PLAN THAT THIS STUDENT IS ON: IEP? 504 PLAN? IFSP ? ISP? NO FORMAL PLAN? 18. AU RESPONSIBLE FOR STUDENT ASSESSMENT FEE: ADDITIONAL INFORMATION: COUNT 2-FEDERAL QUOTA COUNT: Students who meet Federal eligibility requirements of Legal Blindness (MDB or FDB) 1. IS THIS STUDENT TO BE INCLUDED ON THE FEDERAL QUOTA COUNT? YES or NO 2. IF YES, DOES YOUR DISTRICT HAVE SUPPORTING EYE HEALTH DOCUMENTATION ON FILE? IF YES, Date of Eye Report: (Please Attach Copy of Doctor’s Report) NO? SIGNATURE OF TVI COMPLETING THIS FORM: _________________________________________ DATE: PRINTED NAME: SIGNATURE OF SPECIAL EDUCATION DIRECTOR: _________________________________________ DATE: PRINTED NAME: ADMINISTRATIVE UNIT/AGENCY: AU ADDRESS: PHONE: PLEASE RETURN THIS FORM TO COLORADO INSTRUCTIONAL MATERIALS CENTER 1015 EAST HIGH STREET COLORADO SPRINGS, CO 80903 email: cimcregistrations@csdb.org CIMC USE SRS ACCT. AU CODE REVISED 09/2016