Vision Screen Logistics

 

Forms

The following forms should be available in sufficient quantity for the screening event:

 

1. Registration/ Release Form. This form along with a copy of the screening results is kept for our records. Parents/ Guardians must sign the form as a release for the vision screening to take

place. If a child is referred to an eye care provider, place a large letter “R” in the upper right corner of this form.

 

 Registration Form (English)   pdf icon

 Registration Form (Spanish)  pdf icon

 

2. Screening Result Form. This form is provided to the parent and guardian after a verbal briefing is conducted that explains the results. We cannot make a medical diagnosis; however, we can explain that results that fall within or outside of the accepted results. If the results indicate that the child be seen by an eye care provider, we provide this form and the Examiner’s Report. Use the Screening Followup form to recontact those you referred to make sure they made and kept their appointment with an eye care professional.

 Screening Result (English)   pdf icon
 Screening Result (Spanish)  pdf icon

 

 Screening Follow-up  pdf icon

 

3. Have copies of the Prevent Blindness Referral forms for children that may qualify for a free

exam and glasses or provide them access to the Community Eye Clinic.

Forms can be provided to each club electronically so that they may reproduce them and fill in the forms for specific events.