Annual Vision Health Program Evaluation Checklist

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Annual Vision Health Program Evaluation Checklist
Evaluation Date: ___________ Completed By: _____________________________________
Instructions: Review each component described below. Select the “Yes”, “No”, or other response that
best describes your vision health program as it currently operates. Please note comments in the area
indicated. Once you have responded to the questions in each of the components proceed to the “Vision
Health System Action Plan” located on page 7 to identify areas for attention or improvement in your
program.
1. Our program ensures that all parents/caregivers receive educational material, which respects
cultural and literacy needs, about the importance of:
a. Good vision for their child now and in the future.
b. Scheduling and attending an eye exam when their child does not pass vision screening.
c. Increased risk for vision problems in defined high-risk populations.
Check Yes or No
Point of evaluation
Yes
No
We have vision health information in all native languages of the families that we
serve.
Yes
No
We discuss the importance of healthy vision as a part of proper child development in
the general health information provided by our program.
Yes
No
We provide parents with easy-to-understand* information on the visual milestones
for children at all stages of life.
*Information is written at an appropriate reading level, provides graphics as well as descriptions, and
has been tested for ease of understanding.
Our parent/and or health advisory committee(s) have reviewed our vision health
Yes
No
th
information for, content, clarity of instruction, cultural literacy, and reading level (4
N/A
th
to 6
grade level.)
Yes
No
We provide health information to parents of children with special healthcare needs
that describe their increased risk for vision problems.
We have active Parent and Health Advisory Committees
Yes
No
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
2. Our parent/caregiver written approval process for vision screening includes permission to:
Check Yes or No
Point of evaluation
Yes
No
Share screening results with the child’s eye care provider and primary care provider.
Yes
No
Receive eye exam results for our program’s records.
Yes
No
Talk with the child’s eye care provider for clarification of eye exam results and
prescribed treatments.
Yes
No
Share eye exam results with the child’s primary care provider.

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