Iowa Department of Public Health CERTIFICATE OF VISION SCREENING RETURN COMPLETED FORM TO CHILD’S SCHOOL.

Student Information (please print) Student Last Name:

Student First Name:

Parent/Guardian Telephone Number:

Birth Date (M/D/YYYY):

Student Address:

Zip Code:

Screening Information (vision screening provider must complete this section or parents may attach a copy of vision screening results given to them by a provider.) Date of Vision Screening:

________________________________

Results (visual acuity): Right Eye__________

Left Eye__________

Overall Result (Please select one): Pass or

Fail

Referral to eye health professional (Please select one): Yes or

No

Screening Provider: Provider Business Name/Source of Screening: (please print) Provider Name: (please print)

Phone:

Signature and Credentials of Provider:

Date:

A parent or guardian of a child who is to be enrolled in a public or accredited nonpublic elementary school shall ensure the child is screened for vision impairment at least once before enrollment in Kindergarten and again before enrollment in the 3rd grade. To be valid, a minimum of one child vision screening shall be performed no earlier than one year prior to the date of enrollment in Kindergarten and no later than six months after the date of the child’s enrollment in Kindergarten. To be valid, a minimum of one child vision screening shall be performed no earlier than one year prior to the date of enrollment in 3rd grade and no later than six months after the date of the child’s enrollment in 3rd grade. RETURN COMPLETED FORM TO CHILD’S SCHOOL.

Iowa Department of Public Health − B ureau of Family Health 321 E 12th Street - Des Moines, IA 50319 FAX 515-725-1760 − Phone 800-383-3826 http://idph.iowa.gov/family-health/child-health/vision-screening

12/14/2015

Iowa Department of Public Health Child Vision Screening 1. Parents or guardians need to make sure their child has a vision screening at least once before starting kindergarten and again before starting 3rd Grade. 2. Kindergarten Screenings: A screening will be counted if it is done no earlier than 1 year before and no later than 6 months after school starts. 3. 3rd Grade Screenings: A screening will be counted if it is done no earlier than 1 year before and no later than 6 months after school starts. 4. The requirement for a child vision screening will count by any of the following: a. A vision screening or comprehensive eye exam by an eye doctor (ophthalmologist or optometrist). b. A vision screening conducted at a doctor’s office, a free clinic, a child care center, a local public health department, a public or accredited nonpublic school, or a community-based organization or by an advanced registered nurse practitioner or physician assistant. c. A vision screening done by Prevent Blindness Iowa volunteers or Iowa KidSight and Lion’s Club Volunteers. 5. The child vision screening requirement does not apply if the child vision screening conflicts with a parent’s or guardian’s genuine and sincere religious belief. 6. A child will not be withheld from school because a parent or guardian did not provide proof that the child received a vision screening.

Please direct questions regarding vision screening to: Iowa Department of Public Health - Bureau of Family Health 321 E 12th Street - Des Moines, IA 50319 FAX 515-725-1760 - Phone 800-383-3826

Cert of Vision ScrnDec2015 wFacts Fillable_FINAL.pdf

Screening Provider: Provider Business Name/Source of Screening: (please print). Provider Name: (please print) Phone: Signature and Credentials. of Provider: ...

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