Adult Vision Screening and HealthyEyes Webinar Monday, August 14, 2023 , 12:30 pm-3:00 pm Survey

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* 1. Preferred Salutation

Ms.

Miss

Mrs.

Mr.

Dr.

none

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* 2. First Name

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* 3. Last Name

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* 4. Home Address

Street Address

Apt#

City

State

Zip Code

Ohio County

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* 5. Work phone number

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* 6. Home or Cell Phone number

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* 7. Preferred E-mail address

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* 8. Alternate e-mail

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* 9. Job title, volunteer position, or student. If you are a student or volunteer put where you go to school or where you volunteer (or plan on volunteering.) Include the address and organization below.

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* 10. Work Address

Organization

Address

City

State

Zip Code

Ohio County

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* 11. Once you complete training, are you willing to be contacted to provide vision screenings in your area?

Yes

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* 12. Have you been certified as an adult vision screener by Prevent Blindness in the past?

Yes

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* 13. If yes, are you taking this class to re-certify?

Yes

Other (please specify)

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* 14. If yes, do you have the near and distance charts as well as Registration/Risk Assessment Forms?

Yes

Other (please specify)

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* 15. This next group of questions is the pre-test.
Please complete and click "done" at the end.
What is the center portion of the retina where the sharpest vision can be achieved?

Cornea

Iris

Macula

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* 16. What is the clear, transparent outer layer of the eye that protects the front of the eye?

Cornea

Lens

Retina

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* 17. Which of the following are the most common eye diseases in aging adults?

Age-related macular degeneration

Cataracts

Diabetic retinopathy

Glaucoma

All of the above

None of the above

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* 18. Age-related macular degeneration is a disease that affects

Side (peripheral vision)

Central vision

Both side and central vision

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* 19. Which of the following is NOT a factor that increase the risk of diabetic retinopathy?

Living with diabetes

Being black or Hispanic

Not smoking

Poor blood sugar control

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* 20. You can lower your risk of eye disease and vision loss if you:

Avoid smoking

Eat healthy food

Stay active

Protect your eyes from the sun

All of the above

None of the above

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* 21. Controlling your blood pressure is a good idea for protecting your eyesight.

True

False

Adult Vision Screening and HealthyEyes Webinar Monday, August 14, 2023 , 12:30 pm-3:00 pm

Registration-August 14, 2023

Question Title

* 1. Preferred Salutation

Question Title

* 2. First Name

Question Title

* 3. Last Name

Question Title

* 4. Home Address

Question Title

* 5. Work phone number

Question Title

* 6. Home or Cell Phone number

Question Title

* 7. Preferred E-mail address

Question Title

* 8. Alternate e-mail

Question Title

* 9. Job title, volunteer position, or student. If you are a student or volunteer put where you go to school or where you volunteer (or plan on volunteering.) Include the address and organization below.

Question Title

* 10. Work Address

Question Title

* 11. Once you complete training, are you willing to be contacted to provide vision screenings in your area?

Question Title

* 12. Have you been certified as an adult vision screener by Prevent Blindness in the past?

Question Title

* 13. If yes, are you taking this class to re-certify?

Question Title

* 14. If yes, do you have the near and distance charts as well as Registration/Risk Assessment Forms?

Question Title

* 15. This next group of questions is the pre-test. Please complete and click "done" at the end.What is the center portion of the retina where the sharpest vision can be achieved?

Question Title

* 16. What is the clear, transparent outer layer of the eye that protects the front of the eye?

Question Title

* 17. Which of the following are the most common eye diseases in aging adults?

Question Title

* 18. Age-related macular degeneration is a disease that affects

Question Title

* 19. Which of the following is NOT a factor that increase the risk of diabetic retinopathy?

Question Title

* 20. You can lower your risk of eye disease and vision loss if you:

Question Title

* 21. Controlling your blood pressure is a good idea for protecting your eyesight.

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* 22. Questions or comments

* 15. This next group of questions is the pre-test.
Please complete and click "done" at the end.
What is the center portion of the retina where the sharpest vision can be achieved?