Eye Report Form For Children With Visual Problems Page 2
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2Georgia Department of Education
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CONFIDENTIAL
III. If unable to obtain Snellen Acuity, please commit to one of the following by placing an X in the
space.
We are not allowed to accept statements like Fixes and Follows, Central, Maintained, and Steady or the
term Legally Blind in lieu of an acuity. Thank you for your help in this matter and for continuing to provide
quality eye care for the students in the State of Georgia.
Counts Fingers
OD _____ OS _____
Light Perception
OD _____ OS _____
Object Perception
OD _____ OS _____
No Light Perception OD _____ OS _____
Hand Movements
OD _____ OS _____
Functions at the Definition of Blindness* OD _____ OS _____
*Functions at the Definition of Blindness (FDB) is used to indicate blindness due to brain injury or
dysfunction. A student whose visual performance is reduced by a brain injury or dysfunction may be
considered blind for educational purposes when visual function meets the definition of blindness as
determined by an eye care specialist or neurologist. Students in this category manifest unique visual
characteristics often found in conditions referred to as neurological, cortical, or cerebral visual impairment.
An ocular diagnosis must accompany this category on page 1 such as Cortical Visual Impairment.
This is a proven non-changing condition such as bilateral enucleations, anophthalmos, or
other condition determined immutable – condition is: _____________________________
Treatment Recommended:
Glasses and/or contact lenses (please state when and to what extent glasses are to be worn
1.
):
______________________________________________________________________________________
Was a prescription issued? YES Prescription: _____________________NO
2.
Surgery,medication,etc.:____________________________________________________
_______________________________________________________________________
3.
Other Recommendations:
Lighting levels:________________________________________________________
Physical activities:______________________________________________________
Use of other aids (e.g. magnifiers and special lenses):__________________________
Doctor’s Name Printed____________________________ Address _______________________
_______________________
_______________________
Doctor’s Signature_______________________________________ MD or OD
(circle one)
Date of most current eye exam:____________________________
:_______________
I give permission for my child’s eye physician to release the above information for
Date
educational purposes:______________________________________________
Parent/guardian signature
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