7. Kansas Vision Screening Referral & Eye Care Professional Report (Return completed report to school health clinic or nurse) Child’s Name: Date of Birth: Date of Referral:

School: Grade:

Met referral criteria (check applicable boxes): [ ] With Glasses/Contacts [ ] Without Correction [ ] Unable to Screen

[ ] Based on Observation. Provide Symptoms/Concerns:

[ ] Distance Visual Acuity [ ] R [ ] L Circle screening tool/distance: Sloan Chart, LEA Symbols, HOTV Symbols, Chart 5 or 10 feet

[ ] Near Visual Acuity [ ] R [ ] L (or) if Near Binocular Testing [ ] Both [ ] Stereopsis (PASS 2)

Instrument Screening (screener may attach instrument report): [ ] With Glasses/Contacts [ ] Without Correction

Circle Instrument (WA Spot™ / Plusoptix S12C / WA SureSight 2.25) Met referral criteria: [ ] R [ ] L

Eye Care Professional Findngs

Date of Exam:______Without Correction With Current Prescription With New Prescription [ ] Normal R______L______R______L______R______L______Summary of vision problem & diagnosis: [ ] Hyperopia: Indicate eye R______L______[ ] Myopia: Indicate eye? R______L______[ ] Astigmatism: Indicate eye R______L______[ ] Amblyopia: Indicate eye R______L______[ ] Eye Alignment: Indicate eye? R______L______Esophoria / Esotropia / Exophoria / Exotropia / Other [ ] Binocularity (Stereovision, Near Point of Convergence): ______[ ] Other Ocular Conditions or Neurological/ Cortical Vision Impairment – Explain: Recommendations & Treatment:

Glasses Prescribed: [ ] No [ ] Yes [ ] Constant Wear [ ] Near Vision Only [ ] Far Vision Only [ ] May Remove for Physical Education

[ ] Glasses Other ______[ ] Contact Lenses ______

[ ] Medical /Surgical Treatment (e.g., patching, Atropine drops, etc.) ______

Additional Instructions for Teachers - Upon completion of any needed eye care treatment, I expect there will be:

[ ] No significant visual problems that may interfere with learning.

[ ] Visual problems/impairment that may interfere with learning. Explain (see below):______

[ ] Preferential seating [ ] Low vision evaluation [ ] Assistive technology [ ] Lighting conditions [ ] Other:______

[ ] Currently receives services through local Teacher of Students who are Blind or Visually Impaired or Kansas State School for the Blind

[ ] If a child has both a vision and hearing loss, refer family to the Kansas Deaf-Blind Project https://www.kansasdeafblind.org

Next appointment scheduled? [ ] No [ ] Yes If yes, when______

Eye Care Professional Consent of Parent or Guardian I agree to release the above information on my child or ______ward to appropiate school or health authoritties. Signature Date

______Parent or Guardian Signature Date ______Printed Name Send completed report to: (Place school name, address, fax #, etc. here.) ______Address ______City State Zip ______Phone Number

This form is intended for the sole use of the intended recipient and may contain privileged, sensitive, or protected health information. If you are not the intended recipient, be advised that the unauthorized use, disclosure, copying, distribution or action taken reliant on the contents of this communication is prohibited. Document Source: Adapted from Ohio Department of Health Vision Screening Requirements and Guidelines for Preschool and School-Aged Children, 2017