Student / DOB GR / School YR
Parent/Guardian / Cell / Home / Work
Teachers / 5Car 5Bus Bus #

5Medicaid 5Healthchoice 5Private 5Children’s Vision Program (RMt) 5NCFPSC 5PBNC/VSP

Vision Screening
Initial Screen / Date: / Glasses Y N / Wall Chart / Titmus / Telebinocular / Hand Chart
Results / Right / 20/ / Left / 20/ / Both / 20/ / Pass / Retest
Screened by
Re-Screen / Date: / Glasses Y N / Wall Chart / Titmus / Telebinocular / Hand Chart
Results / Right / 20/ / Left / 20/ / Both / 20/ / Pass / Refer
Screened by
Lang II Stereopsis / Pass / Fail / Cover/Uncover / Pass / Fail / Date: / Initial
Symptoms (Check all that apply): / Blurry vision / Can’t see board / Can’t see to read / Headaches / Tilts head
Watery eyes / Eyes drift / Broken glasses / Lost glasses / Needs annual exam
Vision Referral Letters Home / Contacts with parent/guardian
Date / With Student / Mailed / Date / Text / Email / Spoke w / v.m.
Date / With Student / Mailed / Date / Text / Email / Spoke w / v.m.
Date / With Student / Mailed / Date / Text / Email / Spoke w / v.m.
Comments:
Hearing Screening [Hearing Impaired Students are not screened by School Nurse. They are followed by an Audiologist.]
Initial Screen / Re-Screen
Right Ear / Left Ear / Right Ear / Left Ear
1000Hz / db / 1000Hz / db / 1000Hz / db / 1000Hz / db
2000Hz / db / 1000Hz / db / 2000Hz / db / 1000Hz / db
4000Hz / db / 1000Hz / db / 4000Hz / db / 1000Hz / db
Pass / Retest / Pass / Refer
Date / Date
Screened by / Screened by
Hearing Referral Letters Home / Contacts with parent/guardian
Date / With Student / Mailed / Date / Text / Email / Spoke w / v.m.
Date / With Student / Mailed / Date / Text / Email / Spoke w / v.m.
Date / With Student / Mailed / Date / Text / Email / Spoke w / v.m.
Comments: