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Wisconsin National Agenda

Wisconsin Department of Public Instruction

from http://www.dpi.state.wi.us/dpi/een/pdf/2015.pdf

INSTRUCTIONS: To completed by a vision care specialist (ophthalmologist or optometrist). Send a completed copy to the referring individual or to the child's school district.
TYPE OR PRINT
CONFIDENTIAL
COMPLETE BOTH PAGES

I. GENERAL INFORMATION

Student's Name ----
Sex ----
Date of Birth ----
Name of Parent ----
Address of Parent Street, City, County, State, Zip ----
Telephone Area/Number ----
Signature of Parent* ----
Date Signed ----

*Consent: Parent signature for Voluntary Release to county agency (if the child is B-3), local school district, Department of Public Instruction for purposes of educational programming and/or registry with the American Printing House for the Blind. This consent can be revoked at any time, cannot be redisclosed to others for any purpose, and is valid for three years from date signed.

II. REFERRAL

Name of Person Making Referral ----
Address Street, City, State, Zip ----
Telephone Area/Number ----

QUESTIONS AND CONCERNS BY REFERRING PERSON ----
PHYSICIAN RESPONSE ----

Were Low Vision aids recommended?
Yes ---- If Yes, please list.
No ----

III. Signatures

Name of Examiner Please Print ----
Date of Examination ----
Recommended Date For Next Exam ----
Signature of Examiner ----
M.D. ----
O.D. ----
Date Signed ----
Address Street, City, State, Zip ----
Telephone Area/Number ----

Student's Name: ----

IV. MEASUREMENTS

Measurements are:
Accurate ----
Approximate ----

Visual Acuity
Right Eye (O.D.)
Left Eye (O.S.)
Both Eyes (O.U.)
Distant Vision Without Correction With Best Correction
Near Vision in M Sizes Without Correction With Best Correction
Prescription Sph. Cyl. Axis Add
Instruments Used Preferential looking tests VEP (Visual Evoked Response) Lighthouse Feinbloom Snellen Lea Symbols HOTV Other

Is child determined to be legally blind (equivalent to 20/200 Snellen Acuity) for distance vision?
Yes ----
No ----

Field Loss
Tested Yes ---- No ----
If Yes Central ---- Peripheral----
Widest Diameter of Remaining Visual Field In Degrees
O.D. ----
O.S. ----

Is Child Legally Blind for field Restriction: 20 degrees or less
Yes ----
No ----

Does child exhibit deficits in:
Color Blindness ----
Depth Perception ----
Nightblindness ----
If unable to test, does the diagnosis suggest a visual acuity of 2/70 or less in the better eye after correction or a field restriction of 50 degrees or less?
Yes ----
No ----

V. CAUSE OF BLINDNESS OR VISUAL IMPAIRMENT

Present ocular and/or cortical condition(s) responsible for vision impairment and Etiology.
Etiology: ----
Present Ocular Pathology:
O.D. ----
O.S. ----
O.U. ----
Cortical Visual:
Yes ----
No ----

VI. PROGNOSIS AND RECOMMENDATIONS

A. Student's Vision Impairment
Stable ----
Degenerative ----
Uncertain ----
Potentially Degenerative ----
B. Recommended Treatment:
Patching ----
Drops ----
Pressure Checks ----
Low Vision Evaluation ----
Other Specify ----
C. Glasses Check all that apply:
Prescription ----
Tinted Lenses or Sunglasses ----
Safety Lenses ----
Not Needed ----
Worn constantly ----
Worn for distance viewing ----
Worn for close work ----
D. Physical Activities Is there a medical reason for limiting
participation in contact sports or physical education?
No ----
Yes ---- If yes, explain.