Medicaid Eligibility: Yes No Referred: ST. LANDRY PARISH PUPIL APPRAISAL CENTER Yes No VISION REPORT FORM Wearing Glasses / Contacts SCHOOL YEAR 2011-2012 Yes No Name: Date Screened: Homeroom Teacher: School: Grade: Age: INITIAL SCREENING REPORT I. ACUITY FAR POINT LENS LEVER AT Test Result – – “FAR” A Right Eye Left Eye Switch 20 / “Off” B Left Eye Right Eye Switch 20 / “Off” II. ACUITY NEAR POINT LENS LEVER AT Test Result – – “NEAR” A Right Eye Left Eye Switch 20 / “Off” B Left Eye Right Eye Switch 20 / “Off” 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 PRE-K or K Test Result – – “FAR” – A Right Eye Left Eye Switch Manual Allen / “Off” Card Test B Left Eye Eye Switch Yes / No / “Off” V. ACUITY NEAR POINT LENS LEVER AT PRE-K or K Test Result – – “NEAR” – A Right Eye Left Eye Switch Manual Allen / “Off” Card Test B Left Eye Right Eye Switch Yes / No / “Off” VI. MUSCLE BALANCE TEST FAR POINT LENS LEVEL AT Pass Fail – – “FAR” (1) Red Dot - in Box A or B = PASS VII. MUSCLE BALANCE TEST NEAR POINT LENS LEVEL AT Pass Fail – – “NEAR” (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 Alternate Versions Tracking – Near Point of Convergence Hirshberg Pupillary Reflex IX. COLOR BLINDNESS TEST Pass Fail 4 out of 6 = PASS Referral for Eye Examination Parents, Teachers, and Nurses Observations – NURSE’S SIGNATURE TEST ADMINISTRATOR COMMUNICATION SKILLS TEACHER CHECKLIST
Medicaid Eligibility: Yes No Referred: ST. LANDRY PARISH PUPIL APPRAISAL CENTER Yes No VISION REPORT FORM Wearing Glasses / Contacts SCHOOL YEAR 2011-2012 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 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 Alternate Versions – Tracking Near Point of Convergence Hirshberg Pupillary Reflex IX. COLOR BLINDNESS TEST Pass Fail 4 out of 6 = PASS Referral for Eye Examination – Parents, Teachers, and Nurses Observations NURSE’S SIGNATURE TEST ADMINISTRATOR COMMUNICATION SKILLS TEACHER CHECKLIST
AMuvGh8sGP1hlzCky6iH691VQ0NOPeatubefH3j54M6aXxuA.docx