Washington State Department of Services for the Blind

Personal Fact Sheet for Job Seekers Who Are Blind or Visually Impaired

This form is for you to complete to help you assess your abilities and specific accommodation considerations, as they relate to the workplace. The information you provide on this form is for you to use at your own discretion. It may be helpful for you to disclose this information to people who are assisting you in your job search, such as job developers.

Describe the status of your vision.

What is your visual diagnosis?

What are your visual acuities?

In which ways can you use your vision? For example, can you read standard print with a magnifier?

Describe your travel skills.

Describe the type of transportation you use.

What primary media do you use for accessing print? (Check all that apply.)

Large Print

Synthesized Speech/Audio Tape

Braille

Other

Specify:

What basic on-the-job accommodations do you predict you will need?* (Check all that apply.)

Magnifiers

CCTV

Computer Print Enlargement Software

Computer Speech Software

Computer Braille Software

Task Lighting

Note-taking Device

Specify Type:

Other

Specify:

*Note: Our Assistive Technology Unit will assess specific job sites and provide more detailed recommendations.

Explain how you would record and retrieve information for yourself and your co-workers. If applicable, mention the special equipment or tools you use.

What other low vision aids do you use?

Do you have any other medical or disabling conditions? (List them and, if applicable, explain how they could influence your job search.)

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