Form 33.190 - Report Of Vision Screening Form - Los Angeles
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233.190 E/S Rev. 5/01
LOS ANGELES UNIFIED SCHOOL DISTRICT
District Nursing Services
____________________
School
REPORT OF VISION SCREENING
_______________________
Date
____________________________
_____
_____
Student Name
Grade
Room/Track ___
Dear Parent or Guardian:
Your child has received a vision screening at school.
This screening does not replace a complete professional
examination, but is designed to identify those individuals most likely to have a vision problem.
The following results were obtained: Snellen Test: Right eye: 20/____
Left eye: 20/____
Both eyes: 20/____
It is recommended that your child’s eyes be examined by an eye or vision practitioner to determine if a problem exists
which needs correction.
It is requested that you take this form with you, have it completed by the examiner, and then return it to your school nurse.
________________________
School Nurse
__________________________
____)_____________
The school nurse is at school on
Telephone (
If you desire additional information or if you are unable to arrange such care, assistance may be obtained by consulting
the school nurse.
-------------------------------------------------------------------------------------------------------------------------------------------------------------
REPORT OF EYE EXAMINATION TO THE SCHOOL
Student Name:
Birth date
School:
Grade:
Room/Track:
VISUAL ACUITY
_______________
Date examined:
Rt.
Lt.
Both
Rt.
Lt.
Both
_________
Date of re-examination:
Without lens: 20/___
20/___
20/___
With lens: 20/___ 20/___ 20/___
LENS REQUIREMENTS
RESULTS
FREQUENCY
Correction not required
Wear at all times
Correction prescribed:
Glasses
Contact lens
Wear for close work
Wear for distance only
Diagnosis:
Recommendation (special seating, large print, etc.)
Examiner’s signature
Address
Telephone
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