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Run: Vision and Hearing Screening Results and Referral Notification Form

Records school vision and hearing screening results, then documents parent or guardian referral notification when a student does not pass. Use it to keep scr...

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Submission Notice and Privacy Disclosure

Purpose of this submission

I understand this form collects student PII for school health recordkeeping and referral follow-up. (required)

Yes No N/A

Basis for collecting and using this information (required)

Student Information

Student ID (required)

Student name (required)

Date of birth

Collect only if needed to distinguish students with similar names.

Grade level (required)

Screening date (required)

Screening Program Details

Screening type (required)

Reason for screening (required)

Screened by (required)

Screened by role (required)

Vision Screening Results

Vision test method (required)

Vision screening result (required)

Right eye result

Enter the recorded result or acuity value used by your program.

Left eye result

Enter the recorded result or acuity value used by your program.

Vision notes

Hearing Screening Results

Hearing test method (required)

Hearing screening result (required)

Left ear result

Enter the recorded result or threshold used by your program.

Right ear result

Enter the recorded result or threshold used by your program.

Hearing notes

Referral Notification and Follow-Up

Parent or guardian notified (required)

Notification method

Notification date

Reason for referral

Recommended follow-up

Briefly describe the recommended next step, such as eye exam, audiology evaluation, or rescreening.

Documentation, Audit Trail, and Sign-Off

Record status (required)

Additional comments

Submitted by (required)

Submission date (required)

Get your results

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Email (required)

Your name (optional)

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