2021-2022 Hearing-Vision Screening Opt-Out Request - Only complete this form if you DO NOT want your child to be screened.
This form is for parents/guardians who do not want their student to participate in the Lawrence Public Schools Hearing & Vision Screening procedures during the 2021-2022 school year, August 2021 to May 2022.
Lawrence Public Schools conducts Hearing and Vision Screenings mandated by the state of Kansas. To ensure all students can access curriculum and instruction the district screens their Hearing and Distance Vision for concerns that may require further follow-up. The district conducts mass hearing/vision screenings at the schools: Kindergarten through 12th grade. Preschool will receive only Hearing screening. In some grades, not all students participate in the screenings.
COVID-19 PRECAUTIONS: All staff and students involved in Hearing and Vision screenings will wear masks and follow USD 497 COVID prevention and safety measures.
If you want your child's hearing and vision screening to be completed - DO NOT COMPLETE THIS FORM. We will automatically conduct the screenings in accordance with the district protocol for hearing and vision.
If you DO NOT want your child to participate in hearing and vision screening during this school year - PLEASE COMPLETE THIS FORM. Use a separate form for EACH student. This request must be completed by 8:00 a.m. the day before hearing/vision screenings are conducted at your student's school. The date of hearing/vision screenings should be available on your school's calendar and the district website (
If completing a paper form - the paper form must be received by 8:00 a.m. the day before screening by the School Nurse or Health Office Attendant.
Thank you for your time and attention to this matter.
Lawrence Public School Nurses, Nursing Facilitator, and Audiologist
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Student's Full LAST NAME
Student's FIRST NAME
Student's DATE of BIRTH
Student's School of Attendance
I DO NOT want my student's Hearing and Vision screened during the 2021-2022 school year.
Yes, Please DO NOT screen my student's hearing/vision this school year.
Parent/Guardian full name
Relationship to student/child?
Your best contact number and email for questions.
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This form was created inside of Lawrence Public Schools.