Annual Vision Health Program Evaluation Checklist Page 4
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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.
parents/caregivers.
Yes
No
We provide vision screening referral information and follow up to care information in
the native language of all families served by our program.
th
th
Yes
No
Our vision screening referral information is written at a 4
to 6
grade reading level.
Yes
No
Our vision screening referral information has been reviewed and approved by our
parent and health advisory committees.
N/A
Yes
No
The follow-up actions for families are clearly described and parents are advised to
act within a specified timeframe*.
*For example, you may want to suggest that parents schedule an appointment within a week of referral
because the time to receive a scheduled appointment could be as long as 3 months.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
7. We have created a system for following-up with parents/caregivers to help ensure that the eye
exam occurs following a failed vision screening.
Check Yes or No
Point of evaluation
Yes
No
We conduct follow-up calls to families within a set time* after a vision screening
referral.
*Suggested time for follow-up calls is within one month.
We provide electronic reminders (text or email) to families of referred children.
Yes
No
We require a copy of a report from a primary care or eye care provider for all
children referred from a vision screening.
Yes
No
We provide vision accommodations for children with a diagnosed vision problem.
Yes
No
We provide a parent peer-to-peer health support program to families that may need
assistance overcoming barriers to health care (such as transportation, language,
trusted care, adherence to treatment, emotional support, etc.)
Yes
No
We have treatment plans for vision in place for children who have been prescribed
care by an eye care provider.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
8. We link parents/caregivers with resources for eye care and seek out eye care providers who
specialize in the care and treatment of young children.
Check Yes or No
Point of evaluation
Yes
No
We have an updated list of area eye care providers who serve children, and the list is
given to families whose child has been referred for an eye exam (if families do not
have an eye care provider they regularly see.)
Yes
No
We provide families who may be underinsured or not have insurance coverage for an
eye exam and/or glasses with access to programs for free or low cost vision services.
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