• Date:      
    To: Parent/Guardian         From: School Nurse______________________________
    RE: Vision Screening
    Your Child               Grade              
    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:
    Test for nearsightedness.  Your child was unable to read, with each eye alone, the line in a distance chart, which most children can read.   
    DISTANCE CHART-   L eye:                 R eye:                Both eyes:
    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.
    NEAR CHART  -         L eye:                   R eye:                    Both eyes
    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:
       Examination -glasses prescribed   Date     Doctor    
       Examination - NO glasses required   Date     Doctor    
    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.
       I would like to request financial and/or other assistance in obtaining an examination for my child.
       I understand the above information and choose not to have my child examined at this time
    Parent/Guardian Signature       Daytime Phone Number
    School Phone Respond By
    Vision Specialist Evaluation
    Child’s Name       Grade             Date            
    Without correction      R ______________   L _____________
    Acuity- Distance With correction            R ______________   L _____________
    Acuity-Near Without correction       R ______________   L _____________
    With correction            R ______________   L _____________
    Binocular fusion                        Pass                   Fail                 Not Given
    Stereopis: depth perception     Pass                   Fail                 Not Given
                       ¨ Glasses          ¨  Contacts           Additional diagnosis________________
    Prescribed for:  ¨ Distance        ¨  Near                      ¨ Part Time                     ¨ Full Time
    Other Treatment Given:                  
    Date of Next Evaluation                  
    Classroom Recommendations            
    Examiner’s Signature         Office Phone