ABCDEFGHIJKLMNOPQRSTUVWXYZ
2
Tier 1 vision screeningNumber of students screened:
3
(Use a separate registration sheet per class)Number of students referred:
4
5
School:Date/ time:
6
Screening site:Teacher:
7
Passing line:20/40 or 20/32Examiner:
8
9
Student's nameGrade Wears glasses Visual acuity chartRe-screenReferredNotes
10
Right
pass/fail		Left
pass/fail		RightLeftSPOT pass/fail
11
1.P FP F20/20/P F
12
2.P FP F20/20/P F
13
3.P FP F20/20/P F
14
4.P FP F20/20/P F
15
5.P FP F20/20/P F
16
6.P FP F20/20/P F
17
7.P FP F20/20/P F
18
8.P FP F20/20/P F
19
9.P FP F20/20/P F
20
10.P FP F20/20/P F
21
11.P FP F20/20/P F
22
12.P FP F20/20/P F
23
13.P FP F20/20/P F
24
14.P FP F20/20/P F
25
15.P FP F20/20/P F
26
16.P FP F20/20/P F
27
17.P FP F20/20/P F
28
18.P FP F20/20/P F
29
19.P FP F20/20/P F
30
20.P FP F20/20/P F
31
21.P FP F20/20/P F
32
22.P FP F20/20/P F
33
23.P FP F20/20/P F
34
24.P FP F20/20/P F
35
25.P FP F20/20/P F
36
26.P FP F20/20/P F
37
27.P FP F20/20/P F
38
28.P FP F20/20/P F
39
29.P FP F20/20/P F
40
30.P FP F20/20/P F
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101