Vision Screening Form

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VISION SCREENING FORM
Student’s Name
School Year
School
Grade
Initial Examiner
Date
Screening Date:
FAR
NEAR
Both Eyes
[ ] Pass
[ ] Fail
[ ] Pass
[ ] Fail
Examiner:
Instrument used:
Right Eye
[ ] Pass
[ ] Fail
[ ] Pass
[ ] Fail
Remarks:
[ ] Within Normal Limits
Left Eye
[ ] Pass
[ ] Fail
[ ] Pass
[ ] Fail
[ ] Needs Recheck
[ ] With Glasses
[ ] Needs Referral
Recheck Date:
FAR
NEAR
Both Eyes
[ ] Pass
[ ] Fail
[ ] Pass
[ ] Fail
Examiner:
Instrument used:
Right Eye
[ ] Pass
[ ] Fail
[ ] Pass
[ ] Fail
Remarks:
[ ] Within Normal Limits
Left Eye
[ ] Pass
[ ] Fail
[ ] Pass
[ ] Fail
[ ] Needs Recheck
[ ] With Glasses
[ ] Needs Referral
Resolution of Problem:
If the child cannot be conditioned to traditional vision screening, a functional vision screener may be used.
Date:
[ ] Pass
[ ] Fail
Examiner:
Optional Form for Required Procedure/Evaluation
ALSDE Approved Feb. 2014

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