Eye-Gaze Communication Assessment Form
Use this form to evaluate an individual's eye-gaze communication skills and identify support needs. Please complete each section based on your observation.
Observer Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Individual Being Assessed
*
First Name
Last Name
Primary Reason for Assessment
*
Initial evaluation
Progress monitoring
Support planning
Other
Level of Eye-Gaze Control
*
1
2
3
4
5
Consistency of Eye-Gaze Use
*
Consistent
Occasional
Inconsistent
Unable to determine
Input Table: Eye-Gaze Communication Skills
*
Rows
Not Observed
Emerging
Developing
Consistent
Initiates eye contact
1
2
3
4
Maintains gaze to make a selection
5
6
7
8
Shifts gaze intentionally
9
10
11
12
Responds to visual cues
13
14
15
16
Environmental Factors Affecting Eye-Gaze Use
Lighting
Positioning
Device settings
Other people present
Other
Support Strategies Currently Used
Verbal prompts
Visual cues
Physical positioning
Device modifications
Other
Summary of Observations and Next Steps
Submit Assessment
Should be Empty: