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 .