<p> **Please return this form to the school secretary by ______</p><p>VISION SCREENING TEACHER REFERRAL FORM</p><p>School ______Screening Date ______/ ______/ ______</p><p>Poor vision in children can interfere with acquisition of skills and the ability to learn properly. Vision screening is a state requirement (C.E.C. 49455). Effective Fall 2010, vision screening will be conducted for g rades 1 & 4. Teacher referrals for students from other grade levels will be screened at this time. Please enter in the space provided below, students from grades K, 2, 3, 5, 6, 7 or 8 whom you wish to refer for screening. Students must meet a minimum of one of the following criteria in order to be referred:  Students who appear to have visual problems (i.e.: complaints of headaches, squinting, complaints of blurred vision with or without glasses), and students with poor academic performance for unknown reasons.  Students who have or may be referred for a SST or educational testing. State law requires that any student receiving educational testing must have both vision and hearing screening within one year prior to testing.  Students in Special Education who have an upcoming Triennial Review.  Students new to the district</p><p>I am referring the following students for vision screening (screening requires all information to be complete).</p><p>LEGAL NAME ON FILE Gr HO # REASON/SYMPTOMS Glasses SCREENING RESULTS Last Name First Name Y/N (Completed by Screeners Only) R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM Name of Teacher ______Grade ______Room ______</p><p>Room ______Page 2</p><p>LEGAL NAME ON FILE Gr HO # REASON/SYMPTOMS Glasses SCREENING RESULTS Last Name First Name Y/N (Completed by Screeners Only) R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM R20/ M H AS AN P F A R W L20/ M H AS EOM SCREENING RESULTS: RX: Prescription. Wearing glasses during exam. P: Pass EOM: Extraocular Muscles: Eyes tend to deviate from straight position F: Fail/Refer M: Myopia or Nearsightedness. May not see clearly at distances A: Absent H: Hyperopia or Farsightedness. The eyes must focus to see distance clearly and must focus R: Recheck Next Year even more in order to see clearly for reading. W: Color Vision Referral AS: Astigmatism. May result in blurred near and distance vision. May result in headaches. AN Anisometropia: Unequal refractive error</p>