2015-2017 Vision Screener Usage Report
This form is used to document Vision Screener usage. Following a vision screening, complete the following form.
Information from this form is used to track screenings and referrals.
What is the name of the Lions Club sponsoring the screening
Select the sponsoring club from the drop down list.
Big Flats Lions
Elmira College Lions Branch
Hector Area Lions
North Rose Lions
Painted Post Lions
Penn Yan Lions
Southern Tier Retired Lions
Tioga Nichols Lions
Twin Citeis Lions
Union Springs Lions
Which vision screener was used for the screening
Select the owner of the vision screener used for the screening, either the club name or the District.
Pen Yann Screener
Zones_1 (Jo Ann Twist)
Name of the Lion chairing the screening event.
Enter the name of the Lion who chaired the screening event.
Telephone number of the Lion chairing the screening event
Home or cell phones are fine. If this is a privacy issue, this item may be omitted but we would like a phone number or email address (following question) for all screenings.
Enter the e-mail address of the Lion chairing the screening event.
Again, we would like the e-mail address or a contact phone number for every screening.
Enter the name of the Agency or activity where the screening event took place
If the screening did not take place at an agency i.e. a daycare center or school we would like the event name ( health fair at xxx ).
Enter the date ( mm/dd/yyyy i.e. 04/15/2013 ) the screening took place. If you visit a site more than once and perform additional screenings, make an additional entry (do NOT put multiple dates in this field) and note in the comments that this was a return visit and should not be billed again.
Total number of children screened
Enter the total number of children screened durrnig this event
Total number of children referred
Enter the total number of children referred as a result of screenings durring this event
Enter any comments, experiences, suggestions or problems you experienced durring you screening, screener reservation process, etc.
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