INSTRUCTIONAL GUIDELINES FOR VISION SCREENING FORM

This sheet is to be utilized by the school nurse or screening volunteer in order to enable each test to be performed accurately and consistent with all others performing the screening.

School Name: Fill in name of the school.

School Address: Fill in the address of the school.

Name of Student-Grade: Fill in the name of the student and the grade he/she is in.

School Nurses/Screening Personnel: The person performing the screening signs on this line.

Date: Enter the date of the screening.

Fax #: Provide a fax number of where you would like the form returned once it has been completed by an eye care professional.

Screening Report: The school nurse will fill out this section.

Near Vision:

  1. Make sure each eye is completely covered when testing right eye and left eye individually.
  2. Hold the near reading card approximately 16” or 40 cm away from the child’s eyes.
  3. Make sure that the child does not move toward or away from the card.
  4. Document what type of reading card was used (ex. Reduce Snellen card).
  5. Check the appropriate box whether the test was performed “With” or “Without Lenses”.

Far Vision:

  1. Make sure that each eye is completely covered when testing right eye and left eye individually.
  2. Make sure the child is standing at the proper testing distance.
  3. Make sure that the child does not squint while trying to see the letters.
  4. Document what type of chart was used (ex. Snellen, picture chart, lighted).
  5. Check the appropriate box whether the test was performed “With” or “Without Lenses”.

Color Vision:

  1. If the child already wears glasses, this test should be performed “With” the glasses on.
  2. It is recommended that each eye is tested individually.
  3. Hold the color plate book approximately 16” or 40 cm from child.
  4. Have the child call out the colored numbers he/she sees or trace the pattern of color seen (depends on what testing book is being used).
  5. If the child is tracing the patterns of color seen, it is recommended that a q-tip is used as the tracing device to prevent the book from getting dirty.
  6. Document what testing equipment/book was used (ex. Ishihara color plates).
  7. Document the number of correct responses over the number of possible (ex. 13/15).

Depth Perception:

  1. If the child already wears glasses, this test should be performed “With” the glasses on.
  2. This test must be performed using both eyes at the same time.
  3. Hold the depth perception testing equipment approximately 16” or 40 cm from the child.
  4. Have the child call out what he/she sees “popping out” from the book (ex. Butterfly with the Randot Stereogram, fly’s wings with the Stereofly).
  5. Have the child continue to call out all targets (circles or animals) he/she sees “popping out” until the child can no longer determine/differentiate.
  6. Document the number of “arc seconds” the child can get in stereo acuity. (This is a measurement of the amount of stereovision the child has. It will be listed in the stereo book’s instructional manual. Record the number that corresponds to the last picture/circle the child answered correctly.)

Muscle Coordination:

  1. This test is somewhat optional in that it requires significant testing equipment and/or the use of an occluder and the knowledge of how to determine normal eye posturing form abnormal.
  2. If equipment is available and this test is performed, please record results as: Ortho, or Eso/Exo (phoric or topic), and the amount.
  3. Record what equipment was used for this procedure.

Accommodation:

  1. This can be tested if you have +/-3.00 diopter lens flippers.
  2. Requires a near reading card held approximately 16” or 40 cm away.
  3. Instruct child to call out the smallest row he/she can see on the card using both eyes and looking through the minus powered lens. (-3.00)
  4. Then have the child try and call out that row while looking though the plus powered lens. (+3.00).
  5. If the child clearly read the smallest row of letters while looking through the +3.00 lens; the child probably is considerably farsighted, and this should be documented.
  6. If child can clearly read the smallest row of letters while looking though the –3.00 lens, the child has adequate accommodation for the screening.
  7. If equipment other than the +/-3.00 lens flippers where used, pleased record.

Eye Health:

  1. This section can be left blank or feel free to record such comments as:
  • Eyes excessively red
  • Eyes appear mattered
  • Water eyes
  • Any other vision affliction

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