Hearing And Vision Screening Form
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1Ware County Schools Hearing and Vision Screening Form
S-8
Name: ______________________________________________________ Age ______ Sex________ Race _________
Last
First
Middle
Homeroom Teacher ______________________________________School __________________Grade ________
Parent/guardian’s name ___________________________________Home phone ___________________________
Address _______________________________________________Work Phone ____________________________
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Mark box with an X if screening is requested for
SST
IEP
RTI
Gifted
interim screening request
Form 3300
First screening
Screener:
Date:
Screening results
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HEARING
Unable to screen
Frequencies @ 25dB
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Pass
Re-screen
RIGHT
1,000 Hz
2,000 Hz
4,000 Hz
500 Hz
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Fail
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Pass
Re-screen
LEFT
1,000 Hz
2,000 Hz
4,000 Hz
500 Hz
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Fail
VISION
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Unable to screen
No
Wears glasses or contacts?
Yes
No
Tested w/glasses or contacts
Yes
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DISTANCE VISUAL ACUITY TESTING
RIGHT 20/______ or
10/______
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Pass
Fail
Snellen Chart
Lea Symbols™ chart
LEFT
20/______ or
10/______
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Re-screen
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BOTH 20/______ or
10/______
Pass
Fail
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Ocular Alignment – Cover test
Re-screen
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Pass
Fail
Stereopsis – Random Dot ‘E’
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Re-screen
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Pass
Color perception
Color Vision Testing made Easy®
HRR
Ishihara color plates
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(only screen one time
Fail
Previously screened
Date:
ideally before age ten)
Second screening
Screener:
Date:
Screening results
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HEARING
Unable to screen
Frequencies @ 25dB
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Pass
Re-screen
RIGHT
1,000 Hz
2,000 Hz
4,000 Hz
500 Hz
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Fail
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Pass
Re-screen
LEFT
1,000 Hz
2,000 Hz
4,000 Hz
500 Hz
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Fail
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VISION
Unable to screen
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No
Wears glasses or contacts?
Yes
No
Tested w/glasses or contacts
Yes
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Pass
Fail
DISTANCE VISUAL ACUITY TESTING
RIGHT 20/______ or
10/______
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Re-screen
Snellen Chart
Lea Symbols™ chart
LEFT
20/______ or
10/______
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BOTH 20/______ or
10/______
Pass
Fail
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Ocular Alignment – Cover test
Re-screen
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Pass
Fail
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Stereopsis – Random Dot ‘E’
Re-screen
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Date: _________________
Unable to screen letter
Date: _______________
Documentation of professional exam results
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Date: _________________
Referral letter
Date: _______________
Documentation by a professional verifies student has the best
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Date: _________________
Contact parent to confirm receipt
possible correction
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of letter
Date: ________________
Teacher notified
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Follow letter
Date: _________________
Date: ________________
SST coordinator notified
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Parent category: Medical