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Parent/Guardian From: School Nurse______________________________ |
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Vision Screening |
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| Your Child |
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| recently had his/her vision screened and was unable to pass at least one of the following vision tests. New Indiana Code (IC 20-34-3-12) mandates us to notify you of these non-passing results: |
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Test for nearsightedness. Your child was unable to read, with each eye alone, the line in a distance chart, which most children can read. |
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DISTANCE CHART- L eye: R eye: Both eyes: |
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| Test for farsightedness. Your child showed a greater amount of farsightedness than would be expected for his/her age. This may indicate an inability to see comfortably and clearly at close range. |
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NEAR CHART - L eye: R eye: Both eyes |
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| It is recommended that your child have a professional eye examination to rule out the possibility of a visual problem. PLEASE RETURN THIS NOTICE TO THE SCHOOL AFTER THE EXAMINER HAS COMPLETED AND SIGNED THE REVERSE SIDE |
| If your child has had a professional eye examination within the PAST SIX MONTHS, please complete the following: |
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>Examination -glasses prescribed |
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Doctor |
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Examination - NO glasses required |
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| Every effort has been made to ensure accuracy and reliability during the testing. However, this testing is only a screening, not a complete eye exam. An eye exam to rule out and possibly correct, early vision disorders will benefit your child in many ways. Remember most of what your child learns in school is through his/her vision. |
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I would like to request financial and/or other assistance in obtaining an examination for my child. |
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I understand the above information and choose not to have my child examined at this time |
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| Parent/Guardian Signature |
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Respond By |
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| Vision Specialist Evaluation |
| Child's Name |
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Grade |
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| Examination |
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Without correction R ______________ L _____________ |
| Acuity- Distance |
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With correction R ______________ L _____________ |
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| Acuity-Near |
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Without correction R ______________ L _____________ |
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With correction R ______________ L _____________ |
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| Binocular fusionPass Fail Not Given |
| Stereopis: depth perceptionPass Fail Not Given |
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| Recommendations |
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| ¨ Glasses ¨ Contacts Additional diagnosis________________ |
| Prescribed for: ¨ Distance ¨ Near ¨ Part Time ¨ Full Time |
| Other Treatment Given: |
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| Date of Next Evaluation |
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| Classroom Recommendations |
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| Examiner's Signature |
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Office Phone |
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| RETURN INFORMATION TO SCHOOL |
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