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.
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What is the name of the Lions Club sponsoring the screening *
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.
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 ).
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.
Number of children screened *
Enter the total number of children screened during this event
Number of children referred *
Enter the total number of children referred as a result of screenings during this event
Enter any comments, experiences, suggestions or problems you experienced durring you screening, screener reservation process, etc.
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