Impact of Vision Impairment for Children (IVI-C) Form
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© Centre for Eye Research Australia 2010             www.cera.org.au
Student First Name *
Student Last Name *
Date of Birth
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Clinic Location *
Clinic Date *
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Name of person completing the form *
Relationship to student *
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? *
Are you confident to make your own way to school? *
Are you confident to use public transport (such as buses, trains, ferries) by yourself? *
Are you confident in places you don't know? *
Are you confident that you can move around safely in places you don't know in the daytime? *
Are you confident that you can move around safely in places you don't know at night-time? *
Can you find your friends in the playground at lunch and play time? *
When you are in a room, can you recognize people you know before they speak to you? *
Can you take part in games or sports that you want to play with your friends? *
Do you get the chance to go to activities other than sport (such as social groups)? *
Has your eyesight stopped you from doing things you want to do? *
Do other students help you when you ask for help? *
Do other students help you to join in with them? *
Do you find it hard to join in with other students? *
Do you get frustrated? *
Do other students understand your special needs? *
Do your teachers understand your special needs? *
In the classroom, do you get all the same information as the other students? *
Do you get all the information at the same time as other students? *
Do you get enough time in school to complete the work set by the teacher? *
When you are in the classroom, are you confident about asking for help you need? *
When you ask for help, do people understand how much help you need? *
Do people tell you that you can't do the things that you want to do? *
Do people stop you from doing the things you want to do? *
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