Important: Please notify us if you decide not to complete this packet
The following items must be completed and returned to Mira USA as part of the Mira USA Guide Dog application process. Please use this page as your checklist. Email all forms to info@mirausa.org or mail them to Mira USA, 510 NW Broad St., Southern Pines, NC 28387.
Required Forms:
□ Orientation & Mobility Report
□ Assessment Skills in Orientation & Mobility for Transitioning to Guide Dog Travel
□ Instructional Training Video Verification Form
□ Publicity Release Form
Required Videos:
□ Video 1 – Outdoor Travel Skills
□ Video 2 – Indoor Travel Skills
Required Training Video:
□ Watch the Instructional O&M Skills Video:
https://www.youtube.com/watch?v=R6TO8YGCX0w
Your student has applied for a Mira USA guide dog. This page is intended for you, the Orientation & Mobility (O&M) Instructor. As you complete each required form or video, please send it to Mira USA as soon as it is finished. Do not wait until the entire packet is completed before submitting items.
Mira USA provides guide dogs to blind American children, ages 11 through 17, completely free of charge. Our program is built on a foundation of safety, independence, and long-term success. Because a guide dog is not simply a mobility tool but a full working partner, students must have a strong foundation in Orientation & Mobility before they can safely and effectively work with a guide dog.
A guide dog cannot decide when it is safe to cross a street—only the handler can. For this reason, candidates must already demonstrate the ability to navigate street crossings independently, identify traffic patterns, and make safe, confident travel decisions. The most successful guide dog partnerships begin with a handler who is mature, responsible, and able to give clear, consistent directions. This evaluation process not only helps us determine whether a student is currently ready for a guide dog but also helps identify specific skills they may need to continue developing to prepare for a successful future partnership.
Please complete the below Orientation & Mobility Report in full and return it to Mira USA as soon as it is finished. This form provides essential information about your student’s current mobility skills and is required as part of the application process.
We would like you to take videos of your student to show us their current O&M skills. These videos help us understand how your student travels, problem-solves, and manages different environments. Please film both indoor and outdoor travel, and for the outdoor portion, choose a downtown area or a location with defined blocks and traffic. It should be busy enough to demonstrate real street-crossing skills, but it does not need to be extremely busy—your student’s safety is the priority. Most of the video should be filmed from behind as you follow the student, with a brief section filmed from the front. A total of 7–10 minutes is sufficient, and recording on a phone is perfectly acceptable. Parents may assist with filming if needed.
General Rules for Both Videos
• The student must introduce themself at the beginning of each video.
• Do not coach or direct the student unless safety requires it.
• Do not tell the student when to cross a street.
• Follow from as far behind as safely possible.
• Allow students to problem-solve if they go off route.
• Include at least one brief front-facing clip.
• Total combined video time should be 7–10 minutes.
Step-by-Step Instructions
1. Student Introduction
Student states their full name and that they will demonstrate outdoor travel skills.
2. Choose the right location
Select a route with:
a. Consistent traffic
b. Opportunities to use parallel traffic to determine safe crossing times
c. A mix of stoplights, stop signs, and turning traffic
3. Walking portion (3–4 blocks)
Film the student:
a. Walking at least 3–4 blocks
b. Approaching intersections
c. Traveling independently
d. Maintaining a steady pace
e. From behind (safe distance)
f. Include one front-facing clip
4. Required street-crossing demonstration
At one intersection, the student must:
a. Listen to traffic
b. Identify parallel and perpendicular flow
c. Identify turning vehicles
d. Point with arm/hand to show traffic direction
e. Explain when it is safe to cross
f. Use parallel traffic to time the crossing
g. (You may coach only during this demonstration)
5. Additional crossings
Film more crossings showing independence and problem-solving.
You may create a short second video if needed.
Step-by-Step Instructions
1. Student Introduction
Have the student state their full name and that they will be demonstrating indoor travel skills.
2. Choose the right location
Select an indoor environment such as a school, office building, or store—anywhere the student can move through different areas.
3. Entering the building
Film the student locating the entrance, opening the door, and entering independently.
4. Indoor navigation
Film the student walking down hallways, making turns, and navigating unfamiliar areas.
5. Stairs (if available)
If stairs are present, film the student going up or down safely and independently.
6. Functional task
Record the student completing one indoor activity, such as finding a chair and sitting, shopping for an item, retrieving something from a locker, or entering a room to complete a simple task.
7. Exiting the building
Film the student locating the exit, navigating back through the building, and exiting independently.
Front-facing clip
Include a short clip of the student walking toward the camera inside the building.
You may submit your videos in the way most convenient for you.
You may upload the videos to YouTube (public or private) and email the link to info@mirausa.org.
You may also email video files directly if they are small enough. For larger files, upload them to a cloud service such as Google Drive, Dropbox, OneDrive, or iCloud and email the link to info@mirausa.org.
You may also save the videos on a USB flash drive and mail them to:
Mira Foundation USA - 510 NW Broad Street, Southern Pines, NC 28387
Please complete the Assessment of Prerequisite Skills in Orientation & Mobility for Transitioning to Guide Dog Travel and return it to Mira USA as soon as it is finished. This assessment helps us understand your student’s current skill levels and identify any areas that may need further development before they are ready for a guide dog.
Click below to access the Assessment of Prerequisite Skills in Orientation & Mobility for Transition to Guide Dog Travel as a Word document that may be completed electronically, or as a PDF that may be printed, completed by hand, and subsequently scanned.
These are the skills on which your student will be evaluated. You should begin to practice these skills with your student as soon as possible.
If your student is approved for the Evaluation in Canada, you will be invited to travel with them as part of the assessment process. Your involvement helps maintain consistency in instruction and allows you to better understand the expectations placed on your student during their evaluation. All travel expenses for you will be covered by Mira USA.
Evaluation is a 2-day in-person demonstration and evaluation of your student’s O&M and associated skills that will take place at our sister organization in Canada.
It is important for you to know that your student will be tested in an area totally unfamiliar to them. Please try to work as much as possible in unfamiliar areas, especially leading up to their evaluation.
Evaluation Locations and What to Expect
During the Evaluation, your student is typically assessed in three main environments: (1) on campus in Canada, (2) in downtown Saint-Hyacinthe, and (3) in Mont-Saint-Hilaire. Weather conditions may affect specific locations—for example, evaluations have occasionally taken place inside a shopping mall.
Saint-Hyacinthe – “Old Town” Downtown Travel: Most of the critical evaluation work occurs in Saint-Hyacinthe. This area provides defined blocks, consistent traffic, and a variety of intersections—ideal for skill demonstration.
Google Maps: https://maps.app.goo.gl/Bi62rFNERKcTqTbg7 (A commonly used evaluation route begins at: Avenue de la Concorde N & Rue Saint-Amand)
Your student will typically:
Mont-Saint-Hilaire – Four-Lane Traffic Crossing: This is the area where they demonstrate their ability to manage multi-lane crossings safely.
Google Maps: https://maps.app.goo.gl/L71se7jySscKhqQM7
In Mont-Saint-Hilaire, your student will:
Preparing Using Google Maps: This preparation will help you better support your student as they practice similar skills.
You are strongly encouraged to use Google Maps Street View to:
Support From Mira USA
We can arrange a meeting or call with O&M Specialists in who have experience and participated in previous Evaluations and can answer any questions you may have. They are happy to assist and help you understand the expectations and requirements for the evaluation process. Please reach out anytime for support.
If your student is selected to attend the evaluation in Canada, Mira USA invites you to join them for the evaluation. Mira USA will cover the cost of your travel. Your participation is important because it helps support continuity in the student’s training and allows you to observe the evaluation process firsthand.
Because the evaluation takes place in Canada, you will need a valid passport to travel. Mira USA does not cover the cost of your passport. Passport processing times can be lengthy, so if you do not already have one, we encourage you to begin the passport application process as soon as possible.
O&M Instructors must watch the instructional O&M Skills video created in partnership with the Institute Nazareth & Louis-Braille and complete the Instructional Training Video Verification Form after you have watched the video.
Video link: https://www.youtube.com/watch?v=R6TO8YGCX0w
This video provides a clear demonstration of the Orientation & Mobility (O&M) skills Mira USA expects candidates to have before they can work safely with a guide dog. Because O&M instruction varies widely across states, school districts, and instructors, this video ensures everyone is working from the same standard. It shows the key techniques, safety behaviors, and levels of independence the student will need during evaluation and future guide dog travel.
Click below to access the Instruction Video Watch Verification Form as a Word document that may be completed electronically, or as a PDF that may be printed, completed by hand, and subsequently scanned.
Please complete and return the Publicity Release Form as soon as possible. This form gives Mira USA permission to use your photos or videos for evaluation, documentation, and program related purposes. Please call Mira USA if you have any questions.