Submit Vision Screening Report
This form is used to document Vision Screenings completed in MD20. Following a vision screening, please complete this form.
Information from this form is used to track screenings and referrals.
What is the name of the Lions Club sponsoring the screening *
Your answer
Which district is the club from? *
Please choose the district from the dropdown list.
Which vision screener was used for the screening? *
Please select camera type.
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 the screening took place. If you visit a site more than once and perform additional screenings, make an additional entry.
MM
/
DD
/
YYYY
Number of children screened *
Enter the total number of children screened during this event
Your answer
Number of children referred *
Enter the total number of children referred as a result of screenings during 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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