Annual Vision Health Program Evaluation Checklist Page 5
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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.
Yes
No
We create opportunities for local eye care providers to speak with all families we
serve about the importance of healthy vision in young children.
Yes
No
We facilitate families’ access to health insurance coverage for which their child may
qualify (such as a state Medicaid program.)
Yes
No
We have an eye care professional (optometrist or ophthalmologist) with vision
N/A
screening experience on our Health Advisory Committee.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
9. We take steps to ensure receipt of eye exam results on all referred children for their file.
Check Yes or No
Point of evaluation
Yes
No
We use a reminder system to monitor child files to determine whether we received
eye exam results from the eye care provider.
Yes
No
We use the reminder system to contact the eye care provider if eye exam results are
not received within 1 month of the eye exam.
Yes
No
If eye exam results are not received within 1 month of the eye exam, we have a
process to systematically request eye exam results.
Yes
No
If eye exam results are not received after 3 systematic contacts, we stop the process
and indicate in child files that eye exam results could not be obtained.
Yes
No
If we see a pattern of challenges receiving eye exam results from specific eye care
providers, we contact the eye care provider to brainstorm ways to make it easier to
receive eye exam results.
We can report outcome data on completed referrals.
Yes
No
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
10. We help to keep the medical home informed by sending a copy of eye exam results to the child’s
primary care provider.
Check Yes or No
Point of evaluation
Yes
No
We have a system in place to send (mail, fax, e-mail) a copy of eye exam results to
children’s primary care providers.
Yes
No
We indicate in child files the date eye exam results went to children’s primary care
providers.
Yes
No
We indicate in child’s file if we cannot obtain a copy of eye exam results to send to
child’s primary care provider.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
11. We have a process in place to ensure that the eye care treatment plan prescribed for a child is
followed.
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