4. Have non-shatterable lenses been recommended? Yes NoP.O. Box 2033
Hyde Park, New York 12538-8033
Date: _____________________ School: ________________________________
PARENT NOTIFICATION REGARDING VISION
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Pupil’s Name: ______________________________________________ Date of Birth: _________________________________
Address: __________________________________________________ Grade: _______________________________________
To Parent or Guardian:
A recent evaluation indicates that your child may have some eye difficulty. A complete eye examination is recommended to deter-
mine the need for professional care.
This completed form should be returned to the school nurse.
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To Examiner:
The following signs of eye difficulty have been noted by school personnel: ____________________________________________
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________
Your diagnosis and recommendation will help in planning for this child’s school program.
________________________________________
(Signature of School Nurse)
________________________________________
(School Address)
_________________________________________________________________________________________________________
1. Diagnosis: R____________________________________________L______________________________________________
2. Visual acuity (a) Without R_______________________________(b) With R________________________________________
Correction L_____________________________ Correction L____________________________________
3. Under what conditions should glasses be worn?________________________________________________________________
______________________________________________________________________________________________________
4. Have non-shatterable lenses been recommended? Yes No
5. When should this pupil be re-examined? _____________________________________________________________________
6. Recommendations and remarks ____________________________________________________________________________
______________________________________________________________________________________________________
Additional information regarding the child who has a visual handicap:
1. Corrected near visual acuity R________________L_________________
2. Has child been examined for low vision lenses? Yes No
3. Peripheral vision R__________________ L ___________________
If fields are restricted, indicate degree and location _____________________________________________________________
______________________________________________________________________________________________________
4. Should physical activities be limited because of eye condition? Yes No
If yes, please specify _____________________________________________________________________________________
_______________________________________________ _______________________________________________
(Date of Examination) (Examiner’s Signature and Title)