Form E12S Dohmh Doe – Fill Out and Use This PDF

Return the completed form to the NYCDOHMH School Health Vision Program, 42-09 28TH Street, Box 25, Queens NY 11101-4132

NYC DEPARTMENT OF HEALTH AND MENTAL HYGIENE

NYC DEPARTMENT OF EDUCATION

EYE REPORT AND RECOMMENDATIONS

*Date of issue:		*Issued by:		*Title:

*Reason for issue:

TO THE PARENT: Your child did not pass one or more parts of the vision screening. Please take your child to an eye doctor for an eye examination.

SCREENING RESULTS:
Date of screening:				Team code:					Note: 20/40 and up equals Fail
FAR VISION	Pass		Fail				NEAR VISION		Pass Fail
Without glasses			With glasses				Without glasses			With glasses
20/			20/		Right eye
20/			20/		Left eye
20/			20/		Both eyes		20/			20/

Flipper test right eye (+2.50):			Pass	Fail		Fusion:			Pass	Fail
Flipper test left eye (+2.50):			Pass	Fail		Color test:			Pass	Fail
TO THE EYE DOCTOR: Please fill out all fields, especially the fields marked with a red asterisk.*
EYE DOCTOR’S EXAMINATION:
*Date of examination:					*Next visit: (in months)
*Diagnosis:									Right Eye	Left Eye	Both Eyes
1)
2)
3)
4)

*Does this child have a color-perception deficiency?		Yes	No
Your treatment recommendations:
*Are glasses to be worn? Yes	No
*When worn? (Check all that apply):	For near only		Fulltime in class	All the time
	For far only		For class and homework
	For near and far tasks		At child’s discretion

*New prescription Yes No
*Does/will the child wear contact lenses?		Yes	No
*Was child referred to another doctor or facility?			Yes	No
If yes, why?
Amblyopia therapy (if indicated)
*Is patch prescribed for use in school? Yes			No	If yes, in which eye? Right Left Alternating
*Are blurring drops prescribed? Yes		No		For how many hours per day in school?

School accommodations requested:

Special vision services recommended? Yes No If yes, describe

Seating accommodation requested (for children with vision diagnoses only): Yes

Exclude from contact sports? Yes

No If yes, until

Should child wear glasses in gym/sports? Yes No

Sports goggles required?

Yes

No

*Doctor’s last name:

*First name:

*Specialty:

*Facility name:

*Address:

City:

State:

Zip:

*Phone #: (

)

*License #:

*Email address (at least once)

For additional information, please call: 347-396-4747 (Espanol) or 347-396-4721 (English)

E12S DOHMH/DOE (Rev. 5/11)

COPIES: White (Vision Program); Canary (Medical Room); Pink (Parent)

PLEASE SEND ALL COMPLETED FORMS TO:

School Health Vision Program

42-09 28th Street, Box 25

Queens, NY 11101-4132

If you have questions about the form, please call one of the

following numbers:

347-396-4747 (Espanol)

347-396-4759

347-396-4721

If your child has ver y low vision, he or she may be eligible for special services provided by the New York City Department of Education.

Educational Vision Services

The New York City Public Schools provide specialized educational services for students who are blind or visually impaired. Students are eligible if their best-corrected vision in the better eye is 20/70 or lower, or if they have specified visual impairments, such as macular degeneration, retinopathy of prematurity, optic atrophy, high myopia or albinism. Services are designed to give students access to the general curriculum, and to participate in general or special education classes at the highest possible level of independence. Available services include:

●Braille

●Large print reading materials

●Training with low vision devices

●Specialized adaptive computer technology

●Instruction in other skills to attain literacy in:

●reading

●writing

●mathematics

●sciences

●computers

●Instruction in orientation and mobility for independence in travel

●Bus transportation, if needed.

For further information contact:

Educational Vision Services

400 First Avenue, 7th Floor

New York, NY 10010

E12S DOHMH/DOE (Rev. 5/11)