Adult Vision Screening and HealthyEyes Webinar Wednesday, February 18, 2026Noon to 2:30 pm Survey

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1. Preferred Salutation (Required.)

Ms.

Miss

Mrs.

Mr.

Dr.

none

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2. First Name (Required.)

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3. Last Name (Required.)

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4. Home Address (Required.)

Street Address

Apt#

City

State

Zip Code

Ohio County

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5. Work phone number (Required.)

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6. Home or Cell Phone number (Required.)

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7. Preferred E-mail address (Required.)

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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. (Required.)

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10. Do you need any accommodations to attend the webinar? If yes, please describe.

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11. Work Address (Required.)

Organization

Address

City

State

Zip Code

Ohio County

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12. Once you complete training, are you willing to be contacted to provide vision screenings in your area? (Required.)

Yes

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13. Have you been certified as an adult vision screener by Prevent Blindness in the past? (Required.)

Yes

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14. If yes, are you taking this class to re-certify? (Required.)

Yes

Other (please specify)

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15. If yes, do you have the near and distance charts as well as Registration/Risk Assessment Forms? (Required.)

Yes

Other (please specify)

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16. 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? (Required.)

Cornea

Iris

Macula

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

(Required.)

Cornea

Lens

Retina

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18. Which of the following are the most common eye diseases in aging adults? (Required.)

Age-related macular degeneration

Cataracts

Diabetic retinopathy

Glaucoma

All of the above

None of the above

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19. Age-related macular degeneration is a disease that affects (Required.)

Side (peripheral vision)

Central vision

Both side and central vision

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20. Which of the following is NOT a factor that increase the risk of diabetic retinopathy? (Required.)

Living with diabetes

Being black or Hispanic

Not smoking

Poor blood sugar control

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21. You can lower your risk of eye disease and vision loss if you: (Required.)

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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22. Controlling your blood pressure is a good idea for protecting your eyesight. (Required.)

True

False

Adult Vision Screening and HealthyEyes Webinar Wednesday, February 18, 2026Noon to 2:30 pm

Registration- February 18, 2026

Question Title

* 1. Preferred Salutation (Required.)

Question Title

* 2. First Name (Required.)

Question Title

* 3. Last Name (Required.)

Question Title

* 4. Home Address (Required.)

Question Title

* 5. Work phone number (Required.)

Question Title

* 6. Home or Cell Phone number (Required.)

Question Title

* 7. Preferred E-mail address (Required.)

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. (Required.)

Question Title

* 10. Do you need any accommodations to attend the webinar? If yes, please describe.

Question Title

* 11. Work Address (Required.)

Question Title

* 12. Once you complete training, are you willing to be contacted to provide vision screenings in your area? (Required.)

Question Title

* 13. Have you been certified as an adult vision screener by Prevent Blindness in the past? (Required.)

Question Title

* 14. If yes, are you taking this class to re-certify? (Required.)

Question Title

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

Question Title

* 16. 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? (Required.)

Question Title

* 17. What is the clear, transparent outer layer of the eye that protects the front of the eye? (Required.)

Question Title

* 18. Which of the following are the most common eye diseases in aging adults? (Required.)

Question Title

* 19. Age-related macular degeneration is a disease that affects (Required.)

Question Title

* 20. Which of the following is NOT a factor that increase the risk of diabetic retinopathy? (Required.)

Question Title

* 21. You can lower your risk of eye disease and vision loss if you: (Required.)

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* 22. Controlling your blood pressure is a good idea for protecting your eyesight. (Required.)

Question Title

* 23. Questions or comments

Adult Vision Screening and HealthyEyes Webinar
Wednesday, February 18, 2026
Noon to 2:30 pm

1. Preferred Salutation (Required.)

2. First Name (Required.)

3. Last Name (Required.)

4. Home Address (Required.)

5. Work phone number (Required.)

6. Home or Cell Phone number (Required.)

7. Preferred E-mail address (Required.)

8. Alternate e-mail

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. (Required.)

10. Do you need any accommodations to attend the webinar? If yes, please describe.

11. Work Address (Required.)

12. Once you complete training, are you willing to be contacted to provide vision screenings in your area? (Required.)

13. Have you been certified as an adult vision screener by Prevent Blindness in the past? (Required.)

14. If yes, are you taking this class to re-certify? (Required.)

15. If yes, do you have the near and distance charts as well as Registration/Risk Assessment Forms? (Required.)

16. 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? (Required.)

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

(Required.)

18. Which of the following are the most common eye diseases in aging adults? (Required.)

19. Age-related macular degeneration is a disease that affects (Required.)

20. Which of the following is NOT a factor that increase the risk of diabetic retinopathy? (Required.)

21. You can lower your risk of eye disease and vision loss if you: (Required.)

22. Controlling your blood pressure is a good idea for protecting your eyesight. (Required.)

23. Questions or comments