[ NDSIP Home ] [ University of Nevada, Reno ] [ College of Education ] [ Contact Us ]

Usher Syndrome
Behavioral Observations

To return to the Screening Forms Menu please use the "x" on the upper right hand side of this window.

Date: _______________________________________
Name of Child: ______________________________
Birth Date: __________________________________
Completed by: _______________________________

Night Blindness

_____	Has difficulty seeing when coming in from bright sunlight.
_____	Trips over things when light changes or when light is dim.
_____	Stays near light in a dark room or at night.
_____	Positions self so light falls on face of a speaker.
_____	Has difficulty seeing seats of people in a darkened room (e.g., movie theater).
_____	Avoids conversation in a darkened area
_____	Staggers or loses balance after an oncoming car has passed at night.
_____	Has problems reading in dimly lit areas.

Restricted Visual Field

_____	Stumbles on stairs and curbs.
_____	Bumps into people, tables, and chairs, etc.
_____	Has accidents at mealtime with objects placed to the side (e.g., spilled glasses).
_____	Startles easily, "jumpy".
_____	Seems to hold eyes in different directions when looking at some things.
_____	Turns head while reading across a page.
_____	Uses fingers to mark place while reading.
_____	Has difficulty finding small objects that have been dropped.
_____	Fails to glance at another person's hand wave from the side.
_____	Is quiet or edges to one side when in a large group.
_____	Frequently misses or fails to understand group instructions.

Glare Sensitivity

_____	Squints and shades eyes in bright lights or fluorescent lighting.
_____	Likes to wear sunglasses even in a building, but especially in bright light.
_____	May appear awkward when exiting from a building (when faced with bright lights).

Needs Contrast

_____	Has difficulty reading light copies or ditto copies.
_____	Can't see stars at night.
_____	Often spills when pouring liquids.

Problems with Acuity

_____	Holds book close to eyes or bends forward to read.
_____	Sits close to blackboard.

Balance Problems
(Especially important for Usher syndrome, Type I)

_____	Late learning to walk (past 15 months).
_____	Is considered clumsy.
_____	Loses balance easily in dark.
_____	Could not learn to ride a bicycle or required a long time to learn.
_____	May have vestibular loss resulting in balance problems.

Other

_____	Is frequently last in completing group activities.
_____	Exhibits anxiety in new areas.
_____	Often last to enter a room.
_____	May have repetitive behavior or routines at particular times.
_____	May fail to participate fully in group activities associated with new situations in dark or dimly lit areas (e.g., parties, dances, outdoor games).
_____	Frequently hesitates at the top or bottom of the stairs.
_____	Avoids walking or running in unfamiliar areas, especially in bright sunlight or darkened areas.
_____	Constantly appears to be visually scanning a group.

If several items are marked throughout the whole checklist, the individual should receive furhter screening. Refer to the "Dark Adaptation Screening" and "Visual Field Screening." Any suspicions should be medically evaluated by an ophthalmologist or optometrist.