VISION SCREENING HANDICAPPED CHILD
(when regular screening methods cannot be used)
(Ref. PL 94-142)

Name___________________Sex______D.O.B.__________Room or Teacher____________

School___________________City_______________County______________State________

Period of Observation (3-5 Days)_______________Screener______________ Date_______
  Yes No Comments Observations
1. Does child have opacity (cloudiness of cornea) or any other obvious abnormality of the eyes?
       If answer is yes, child may have a cataract or other problem. Refer if there is no previous record of condition.
2. Is child wearing glasses?
       If answer is yes, screen child with glasses on.
3. Does child appear to have problem with glasses, i.e., consistently looking over top or side of glasses if he has glasses?
       If answer is yes, screen child with and without glasses.
4. Does child appear to function as well, if not better, without glasses if he has glasses?
       If answer is yes, suggest another evaluation.
5. Does child react only to light i.e., looking toward light, windows, or sunlight?       If answer is yes, it may indicate child has limited vision. If answer is no, it may indicate child has reasonably good vision if there is normal reaction to environment.
6. Does child recognize new or familiar objects (foods, toys) or imitate gestures (waving, returning smile)?

At near_______

At far________

       Observe if child sees or reacts to:
  1. food items on plate
  2. toys or other familiar object at 2 to 5 foot distance and 10 to 20 foot distance
  3. waving at 2 to 5 foot distance and 10 to 20 foot distance.
7. Does child hold eye contact:

With you?____________

With strangers?________

       If answer is yes, child has good muscle control and usable vision. If answer is no, may indicate child has poor vision or is simply disinterested.
8. Does child have eyes that deviate in or out or have problem controlling pupils which interferes with learning tasks:

At near point?_________

At far point?__________

  

 

 

 

 

  

 

 

 

 

  

 

 

 

 

 If there is deviation or lack of control, this may indicate a STRABISMUS. To detect a hidden strabismus, do cover-uncover test explained in the Vision Screening Guidelines (pg. 22). A drifting or other uncontrolled movement is abnormal. If a strabismus has been previously identified, and decision was made not to correct it, child need not be referred for further evaluation of this problem. Document all information.
9. Does child react to familiar objects or follow movements of objects:

Right-left?____________

Left-right?____________

       If child reacts or follows movements of familiar objects right-left and left-right, it may indicate child has reasonably good vision and good muscle control. If answer is no, it may mean poor vision or simply lack of interest.
10.  Is there normal or abnormal positioning of head when objects or tasks are presented:

At near point?________

At far poing?_________

       Abnormal positioning of head may indicate a vision problem. If there is no previous record of eye examination, this is reason to refer.
11.Findings:

 

         

 Considering all of the above, provide an overview about child's vision.  Does child appear to have or not have functional vision to accomplish tasks.
12. o No referral indicated
      o   Referral indicated for professional eye examination		 Record decision to refer or not to refer for an eye examination.

Revised 7/2000