If you are entering information for multiple schools in your district, please complete one survey per school, NOT per district. Once you have entered information into the survey for one school, restart the survey and enter information for the next school.

* 1. Name of person completing this report:

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

* 3. Title of person that conducted the screenings:

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

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

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