Vision Letter to Parents

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
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 fusionPass Fail Not Given
Stereopis: depth perceptionPass 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