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.
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.
Name of the Lion chairing the screening event. *
Enter the name of the Lion who chaired the screening event.
Your answer
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.
Your answer
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.
Your answer
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 ).
Your answer
Screening Date *
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.
MM
/
DD
/
YYYY
Total number of children screened *
Enter the total number of children screened durrnig this event
Your answer
Total number of children referred *
Enter the total number of children referred as a result of screenings durring this event
Your answer
Comments
Enter any comments, experiences, suggestions or problems you experienced durring you screening, screener reservation process, etc.
Your answer
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