Student Nurse Health Assessment Skills Checklist Template Page 2
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2Document if student tells you his/her glasses are lost or broken.
Vision—Far
Done w/o prompt Done w/prompt
Not Done
Have student wear own glasses (if they do so normally).
Ask K-1 kids to read HOTV chart to see if they know the letters.
Use matching card with students unable to identify letters.
Start with right eye and cover left eye with cover glasses or
occluder.
Have student start with top line. Student can advance to 20/30
when 3 of 4 letters are correct. Student will pass 20/30 line
when 4 out of 6 letters are correct.
Switch and cover right eye with cover glasses or occluder.
Have student start with top line. Student can advance to 20/30
when 3 of 4 letters are correct. Student will pass 20/30 line
when 4 out of 6 letters are correct.
Record results legibly on assessment tool.
Mark “with correction” if student wore their own glasses.
Document if student tells you his/her glasses are lost or broken.
Vision—Random Dot E
Done w/o prompt Done w/prompt
Not Done
Have student wear their own glasses (if they do so normally).
Place polarized glasses on student (leave child’s glasses on if
applicable).
Demonstrate with model “E” card.
Hold cards at eye level and ask student to identify “E”
Start testing at 20”. Must get 4 of 6 correct to pass.
If student passes, move to 40” and assess again. Must get 4 of 6
correct to pass
Mark “with correction” if student wore their own glasses.
Document if student tells you his/her glasses are lost or broken.
Vision—Near
Done w/o prompt Done w/prompt
Not Done
Have student wear their own glasses (if they do so normally).
Cover left eye, hold cord at corner of eye until taut.
Start with top line, student passes with 3 of 4 correct.
If student passes, move to 20/30. Passes with 3 of 4 correct.
Cover right eye, hold cord at corner of eye until taut.
Start with top line, student passes with 3 of 4 correct.
If student passes, move to 20/30. Passes with 3 of 4 correct.
Mark “with correction” if student wore own glasses.
Clean glasses/covers after approximately 10 uses and as needed.
Document if student tells you his/her glasses are lost or broken.
Instructor Name:_____________________________
Peer Name: ____________________________
Instructor Signature:__________________________
Peer Signature: _________________________
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HIS FORM MAY NOT BE REPRODUCED OR USED FOR OTHER PURPOSES WITHOUT WRITTEN PERMISSION FROM
CORE
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