Annual Vision Health Program Evaluation Checklist Page 6
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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.
Check Yes or No
Point of evaluation
Yes
No
We contact a child’s eye care provider if we do not understand the eye exam results
or treatment plan.
Yes
No
We review vision treatment plans quarterly to help ensure parents schedule and
attend upcoming eye care provider follow-up visits.
Yes
No
We have a process for contacting the parent if a child does not wear prescribed
glasses or a patch.
Yes
No
We have a process for alerting a child’s eye care provider if the child does not wear
prescribed glasses or a patch.
Yes
No
We have resources to share with parents if their children refuse to wear prescribed
glasses.
We conduct a sensitive child- and family-centered assessment to identify barriers to
Yes
No
following the prescribed vision treatment plan.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
12. We evaluate the effectiveness of our vision health program annually.
Check Yes or No
Point of evaluation
Yes
No
We compare screening results to eye exam outcomes to identify variations or
needed revision in screening procedures.
Yes
No
We ensure that the certifications for all trained vision screeners are current.
Yes
No
We review all vision screening tools annually to ensure they are in good working
order and any software or settings are updated before using them to screen vision of
children
Yes
No
We review our vision health program results annually with our parent and health
advisory committees to identify needs and seek solutions for possible barriers to
follow-up care.
Yes
No
We report our end-of-year data to health, education, and community stakeholders.
Notes: _______________________________________________________________________________
_____________________________________________________________________________________
Next: Proceed to the next page to create your action plan for your children’s vision health system
of care.
Our Children’s Vision Health System Action Plan
Directions: Review your responses from the program evaluation form and the notes written for
each item. In all areas where “no” was the response selected, or your notes indicate a need for
improvement, establish the next steps your program will take to improve efforts in that area.
Once all responses have been accounted for, establish your top three priorities out of your
needed actions, a date to review progress, and a completion date.
Needed actions: _____________________________________________________
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