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
REQUIRED TESTS* Pass Fail Recommend Further Evaluation (comments noted below)
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ADDITIONAL TESTS
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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)
