As a business owner, you're likely familiar with the DIFFERENTIATE YOUR BUSINESS FROM COMPETITORS form, also known as the D Se F55 form. This form is used to assess how your business stands out from its competitors, and to identify strategies that can be used to improve your competitive edge. Completing this form can help you focus on areas where your business needs improvement, so that you can stay ahead of the competition. In this blog post, we'll provide a brief overview of the D Se F55 form and explain how you can use it to strengthen your business. Stay tuned for our next blog post, where we'll go into more detail about each section of the form. Thanks for reading!
| Question | Answer |
|---|---|
| Form Name | Di Se F55 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | vision screening forms for school, di se f55, unaided, DI-SE-F55 |
HEARING/VISION SCREENING RESULTS |
Attachment I |
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Student Name:
School:
PART I
Revised, August 1992
Age:
District:
A. HEARING SCREENING
Instrument:
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1st Screening |
2nd Screening |
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PASS |
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FAIL |
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EXAMINER |
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DATE |
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B.VISION SCREENING Instrument:
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1st Screening |
2nd Screening |
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YES |
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YES |
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Screened wearing glasses? |
NO |
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NO |
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Both Eyes |
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Right Eye – Far Vision |
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Left Eye – Far Vision |
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PASS |
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PASS |
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Near Vision |
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FAIL |
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FAIL |
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FIRST |
EXAMINER |
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SCREENING |
DATE |
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SECOND |
EXAMINER |
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SCREENING |
DATE |
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PART II
If an attempt is made to condition a severely handicapped child for hearing/vision screening and no response can be obtained, then a quantitative description of the child’s hearing/vision must be completed by an individual who works with the child.
A.HEARING EXAMINER: DATE:
YES NO
1.Does subject respond to noise, i.e. ringing bell, rattle, etc.?
2.Does subject respond to name when called?
3.Does subject interact verbally or with gestures?
4.Can subject identify body part on verbal command?
5.Does subject respond to simple verbal commands?
6.Can subject point to person or objects when asked?
7.Is imitation of speech present?
8.Does subject’s eyes and/or head turn toward a voice?
9.Does subject react to (not necessarily stop) an activity when he hears “No! No!”?
10.Does subject attend to songs sung to him?
B.VISION EXAMINER: DATE:
YES NO
1.Does subject follow an object with eyes?
2.When using a pencil, crayon, paintbrush, etc., does subject follow markings with his eyes?
3.Does subject pick up objects from table or floor?
4.Does subject reach for objects when handed to him?
5.Does subject grasp objects unaided or without direction from teacher?
6.Does subject look at an object when placed before him?
7.Does subject look at pictures in a book?
8.Do eyes and head turn toward a light that is introduced?
9.Does subject watch own hand movements?
10.Does subject look at self in mirror?
11.Does subject use a visual searching technique when objects are placed out of sight?
Describe additional behaviors in hearing/vision that should be considered in assessment and educational programming: