• 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.

* 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