Guidelines for Vision Screening in Missouri Schools


APPENDIX C: Sample Forms

Report To Parents

Letter Template For Report To Parents

Checklist For Vision

Checklist For Vision including Observation and History, and Signs or Symptoms of Eye Problems

Referral Tracking System

Referral Tracking System (Sample)

School Vision Referral

School Vision Referral Template

HIPAA Compliant Authorization

HIPAA Compliant Authorization Exchange of Health & Education Information

School Vision Screening Form

School Vision Screening Form Including School Functional Vision Assessment Form