Functional Eye Gaze Assessment Purpose Statement: Eye gaze software is most commonly used to help provide communication for persons who cannot verbally speak. The Functional Eye Gaze Assessment is not addressing communication, rather, elements of the software are being used to assess where the eyes focus on the screen while participating in training activities by recording visual fixations. A camera captures the reflection of an infrared light emitted from the camera and uses that reflection to activate elements on the screen. A heat map, gaze plot and screen recording are produced and can be shared as a summary, along with a video of the student’s face. It should be noted that specific calibration to each student is not always completed and different results may be obtained if customized calibration were done. Disclaimer: This informal assessment activity is used to provide additional observation and insight into the student’s functional visual behaviors. Any observations are provided to the educational team as suggestions only and should not be the only data used when making decisions regarding educational assessment, placement or services. Dr. Linda Lawrence, MD and the Kansas State School for the Blind are gathering the data collected in these assessments to further understand and develop this testing for widespread use. Please mark the appropriate items below to agree to participation in the assessment and sharing of the results. While your child’s name, year of birth, image of his/her face and primary visual or medical diagnosis may be collected and stored in a secure database, the sharing of results will not identify your child in any way. No harmful effects are anticipated in the participation in use of the system or sharing of the collected data.Please mark ONE box in each section below. EITHER “I agree” OR “I DO NOT consent”. I agree for my child to participate in the Functional Eye Gaze Assessment. I DO NOT consent for my child to participate in the Functional Eye Gaze Assessment. To us data collected for further development I agree to the use of the data collected for further development of this test by Dr. Lawrence, and/or KSSB. I DO NOT consent to my child’s information being used in any research capacity. Photos/Videos used for education I agree to photographs/videos of my child to be used for education of and/or training in the Eye Gaze Assessment by Dr. Lawrence and/or KSSB. I DO NOT consent to the use of videos or photos outside of my child’s current educational team. Child's Name First Last Date of Birth MM slash DD slash YYYY Parent/Guardian Printed Name First Last Relationship SignatureDate MM slash DD slash YYYY Email address to share results For more information: Anna Cyr, M. Ed, TSVI/COMS, KSSB Field Services Specialistacyr@kssdb.org (913) 645-5324
