School Vision Evaluation Form
SCHOOL VISION EVALUATION
Report Form
A School Vision Evaluation is required for all children within six months prior to entering Nebraska schools for the first time (includes beginner grades including Kindergarteners, transfers, and other students new to Nebraska) [Nebraska Revised Statute 79-214]
Name: _______________________________________ Date of Birth: _________________________
School: ______________________________________ Date: ________________________________
Student Status (check one): ____ Beginner Grade ____Transfer Student from Out of State
Recommend
REQUIRED TESTS* Pass Fail Further Evaluation
(comments noted below)
Amblyopia _____ _____ _____
Strabismus _____ _____ _____
Internal Eye Health _____ _____ _____
External Eye Health _____ _____ _____
Visual Acuity _____ _____ _____
Right eye @ distance (20 ft.): 20/____ aided/unaided
Left eye @ distance (20 ft.): 20/____ aided/unaided
Right eye @ near (16 in.): 20/____ aided/unaided
Left eye @ near (16 in.): 20/____ aided/unaided
*A vision evaluation consisting of these required tests meets the legal requirements for the State of Nebraska but is not a complete eye examination such as most eye doctors perform.
Recommend
ADDITIONAL TESTS Pass Fail Further Evaluation
Eye Alignment at Distance _____ _____ _____
Eye Alignment at Near _____ _____ _____
Depth Perception _____ _____ _____
Color Vision _____ _____ _____
Focusing Amount _____ _____ _____
Focusing Flexibility _____ _____ _____
Focusing Lag (Accuracy) _____ _____ _____
Convergence (Crossing) Ability _____ _____ _____
Saccade (Rapid) Eye Movement _____ _____ _____
Pursuit (Tracking) Eye Movement _____ _____ _____
Other: ______________________ _____ _____ _____
COMMENTS/RECOMMENDATIONS: __________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Evaluation performed by: __________________________________________ Date: _____________________
(signature)
____O.D. ____M.D. ____P.A. ____A.P.R.N.
Original—Doctor Copy #1—Parent Copy #2—School Nurse Copy #3—Placed in student’s permanent file
Nebraska Foundation for Children’s Vision (www.NEchildrensvision.org)
