• If you are entering information for multiple schools in your district, please complete one survey per school, NOT per district.
 
  • If you are a certified preschool vision screener, please complete one survey per screener for each screening location.
 
  • Once you have entered information into the survey for one school, restart the survey and enter information for the next school.

Name of person completing this report:

Question Title

* 1. Name of person completing this report:

Position or title of the person completing this report:

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* 2. Position or title of the person completing this report:

Title of person that conducted the screenings:

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* 3. Title of person that conducted the screenings:

Please complete the following information about the facility or event where the screenings were conducted.

Question Title

* 4. Please complete the following information about the facility or event where the screenings were conducted.

Please provide the phone number of the school or facility where screenings were conducted.

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* 6. Please provide the phone number of the school or facility where screenings were conducted.

Select the type of setting where vision screenings were conducted

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* 7. Select the type of setting where vision screenings were conducted

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