Annual Vision Health Program Evaluation Checklist Page 3
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7Source: Nottingham Chaplin, P. K., Ramsey, J. E., & Baldonado, K. (2014). Children’s vision health: How to create a strong vision
health system of care. Exchange, 36(3), 36-41.
program, a state-approved training program, or according to our state guidelines
We ensure that contracted screening organizations use evidence based tools and
Yes
No
procedures, utilize national referral and rescreening guidelines, and clearly state that
a screening does not replace an eye exam nor provide a diagnosis.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
4. Our program creates policies for screening, referral, and support for the visual health of children
with special healthcare needs.
Check Yes or No
Point of evaluation
Yes
No
We use guidelines from the National Center for Children’s Vision and Eye Health at
Prevent Blindness for when to bypass vision screening and move directly to eye
exam.
Yes
No
We have a process to indicate in a child’s files that the child met national guidelines
to bypass vision screening and move directly to eye exam.
Yes
No
We have a professional relationship with a Teacher of the Visually Impaired (TVI)
from the local school system to answer questions about how to support the visual
health of our children with special healthcare needs.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
5. We have standards in place for re-screening or referring difficult-to-screen (untestable) children.
Check Yes or No
Point of evaluation
Yes
No
If a child will not participate in screening, we make another attempt as soon as
possible, but within 6 months
Yes
No
If we are not successful with the first attempt at screening, we re-screen the child
immediately using a different vision screening tool (test of visual acuity or an
instrument) or at least within 6 months.
nd
Yes
No
If a child is untestable on the 2
attempt, we refer the child for an eye exam
performed by an optometrist or an ophthalmologist.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
6. We provide parents/caregivers with vision screening results in easy-to-understand language,
which respects cultural and literacy needs and provides clearly defined next steps.
Check Yes or No
Point of evaluation
Yes
No
Vision screening results are provided in both a written and verbal format to
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