Introduction: This study investigated the use of accommodations and the performance of students with visual impairments and severe cognitive disabilities on the Pennsylvania Alternate System of Assessment (PASA)yCoan alternate performance-based assessment. Methods: Differences in test scores on the most basic level (level A) of the PASA of 286 students with visual impairments, grouped into one of three functional vision levels, in grades 3/4 or 7/8 were analyzed descriptively as well as inferentially using the non-parametric Kruskal-Wallis and ad hoc Mann Whitney U tests. In addition, teachers of students with visual impairments viewed the videotaped assessments of 257 of these students to record accommodations used. Accommodations data were analyzed for patterns and relationships with test item types. Chi-Squares were calculated. Results: There was a significant difference in test scores by functional vision level, with students who predominantly use vision performing significantly better than students who use a combination of vision and other senses or use other senses in place of vision. The accommodations used generally matched a student's reported level of functional vision with layout and presentation accommodations being the most prevalent. Discussion: The types of accommodations selected may be due to the structure of alternate assessments but also raise questions about what is a progression in reading for students who do not access pictures and print with vision. Differences in performance raise questions of accessibility vs. ability and the level of difficulty of test items when accommodations are used. Implications for practitioners: Practitioners should advocate for guidance from alternate assessments on accommodation use that mirrors the intent of test items and consider how state alternate standards translate when tasks addressing those standards are adapted for students with visual impairments. Test developers should consider students with visual impairments when designing and interpreting alternate assessment test items. (Contains 6 tables.)