Report of School Vision Test - Health Services & School ...
Report of School Vision Test
CDE, T07-001, English
Page 1 of 2
Report of School Vision Test
(This form is approved by the California State Superintendent of Public Instruction, as required by California Education Code Section 49456, for reporting results of vision testing to parents and guardians and for obtaining recommendations from the professional examiner.)
Dear Parent/Guardian:
Your child recently received a vision test at school.
The following results were obtained:
Optotype test: right eye 20/_____ left eye 20/_____
Additional procedures
Comments
It is recommended that your child’s eyes be examined by an eye or vision practitioner.
It is requested that you take this form with you, have it completed by the examiner, and then return it to your school’s health office.
Name of school
Address
Date Grade Teacher Phone
(Signature of school nurse)
|English Version: Report of Vision Test to the School |
|Name of student |School |Grade |Date examined |Date of re-examination |
|Visual acuity |Lens requirements |
|Without lens |With lens |Results |Frequency |
|R 20/____ |R 20/___ |ο Correction not required for right eye |ο Wear at all times |
|L 20/____ |L 20/___ |ο Correction not required for left eye |ο Wear for close work |
| | |ο Glasses ο Contact lens |ο Wear for distance only |
|Diagnosis |Recommendation (special seating, large print, special education |
| |placement, etc.) |
|Examiner’s signature |Address |Phone Number |
I give permission to share this information with the school.
(Signature of parent)
................
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