Screening report form 2016
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The Lions Club of West Virginia conducted a vision screening for multiple age groups at an unspecified event location. They screened individuals ages 6 months to 18 years old using Pediavision or PlusOptix equipment and those 19 years and older using tonometry or visual acuity tests. The report provides the number screened and referred in each age group along with volunteer hours. Results are to be mailed or emailed to the Lions contact for reporting.
Screening report form 2016
- 1. LIONS MULTIPLE DISTRICT 29 WEST VIRGINIA VISION SCREENING REPORT CLUB: _______________________ DATE OF SCREENING:_____________ LOCATION OF SCREENING: _______________________________________________ EVENT: _______________________________________________________________ EQUIPMENT USED: CIRCLE ONE OR MORE OF THE FOLLOWING KidSight Equipment: A. Pediavision “SPOT” B. PlusOptix Adult Equipment: C. Tonometer “Puff Machine” D. Titimus Visual Acuity RESULTS Age Group Numbered Screened Numbered Referred Volunteer Hours 6 Mo. To 6 yrs. 7 yrs. to 18 yrs. 19 yrs. Plus Print Name____________________________Signature______________________________ Email or Telephone___________________________________________________________ Mail or email to: Kim Ebert PO Box 9193 Morgantown, WV 26506 ebertk@wvumedicine.org or Fax to 304-598-6928