Medicaid Eligibility:
Yes / No
Referred:
ST. LANDRY PARISH PUPIL APPRAISAL CENTER / Yes / No
VISION REPORT FORM / Wearing Glasses / Contacts
Yes / No
Name: / Date Screened:
Homeroom Teacher: / School: / Grade: / Age:

INITIAL SCREENING REPORT

I. / ACUITY – FAR POINT – LENS LEVER AT “FAR” / Test Result
A / Right Eye / Left Eye Switch “Off” / 20 /
B / Left Eye / Right Eye Switch “Off” / 20 /
II. / ACUITY – NEAR POINT – LENS LEVER AT “NEAR” / Test Result
A / Right Eye / Left Eye Switch “Off” / 20 /
B / Left Eye / Right Eye Switch “Off” / 20 /
III. / RESCREENING – HOTV / Test Result / ROSENBAUM (NEAR) / Test Result
Right Eye / 20 / / Right Eye / 20 /
Left Eye / 20 / / Left Eye / 20 /
IV. / ACUITY – FAR POINT – LENS LEVER AT “FAR” – PRE-K or K / Test Result
A / Right Eye / Left Eye Switch “Off” / Manual Allen / /
Card Test
B / Left Eye / Right Eye Switch “Off” / Yes / No / /
V. / ACUITY – NEAR POINT – LENS LEVER AT “NEAR” – PRE-K or K / Test Result
A / Right Eye / Left Eye Switch “Off” / Manual Allen / /
Card Test
B / Left Eye / Right Eye Switch “Off” / Yes / No / /
VI. / MUSCLE BALANCE TEST – FAR POINT – LENS LEVEL AT “FAR” / Pass / Fail
(1) / Red Dot - in Box A or B = PASS
VII. / MUSCLE BALANCE TEST – NEAR POINT – LENS LEVEL AT “NEAR” / Pass / Fail
(1) / Red Dot - in Box A or B = PASS

(Perform either the 2 Muscle Balance Tests or Manual Muscle Balance Test)

VIII. / MANUAL MUSCLE BALANCE TEST (R.N. USE ONLY) / Pass / Fail
Cover/Uncover
Alternate Cover
Versions – Tracking
Near Point of Convergence
Hirshberg Pupillary Reflex
IX. / COLOR BLINDNESS TEST / Pass / Fail
4 out of 6 = PASS

NOTES:

Referral for Eye Examination – Parents, Teachers, and Nurses Observations

NURSE’S SIGNATURE TEST ADMINISTRATOR

ST. LANDRY PARISH SCHOOL BOARD

PUPIL APPRAISAL CENTER

127 BLAIR STREET

OPELOUSAS, LA 70570

PHONE: (337) 948-3646

FAX: (337) 948-3644

To the parents/guardians of:
Date / School / Grade / Teacher

The St. Landry Parish School Nurses, as mandated by the Louisiana State Department of Education recently performed a vision screening on your child. Below are the results of your child’s screening.

1) / Your child has failed the screening, and according to state guidelines, this indicates that he/she
needs a more complete eye exam. Please make arrangements, with an eye doctor, if it has been
longer than a year. / Acuity O.D. / O.S. / Failed at least one muscle balance test
RETEST: / HOTV O.D. / O.S.
2) / Your child was tested without his/her glasses, and failed the vision screening, please encourage
your child to wear the prescribed glasses while at school.
3) / Your child failed the vision screening with his/her glasses on, please follow-up with your current
eye doctor to insure the best possible correction.
4) / Your child has voiced complaints that may indicate a need for further and more extensive eye
examination. Complaints:
5) / Your child states that his/her eye glasses were broken on the day of the eye screening. Please
make every effort to have them repaired as soon as possible.
6) / We were unable to test your child using our conventional methods and equipment. Please have
him/her seen by an eye doctor, if it has been longer than a year since last exam.

REPORT OF EYE SPECIALIST

1. / Diagnosis with results without glasses:
2. / Correction Needed: / yes / no / Acuity with correction
3. / Recommendations / Remarks:
4. / Date of Examination:
Physician’s Signature / Printed or Stamped Physician’s Name
Physician’s Address:
Telephone Number: / Fax Number:

Please return entire form to above address.