Form E12S Dohmh Doe PDF Details

The E12S Dohmh Doe form is a crucial document designed to facilitate communication between the school system and healthcare professionals regarding a child's vision health. It's usually filled out when a child does not pass a vision screening conducted at their school. This form serves multiple purposes: to inform parents about their child's failing vision screening results, guide them in seeking further eye examination from an eye doctor, and relay the doctor's examination findings and recommendations back to the school. The document is comprehensive, covering screening results, eye doctor's examination, diagnosis, treatment recommendations, including whether glasses or contact lenses are needed, and if any specific accommodations are required at school to support the child's vision needs. Additionally, it provides information on special services for children with very low vision offered by the New York City Department of Education, aiming to maintain students' access to education despite vision impairments. The completed form must be returned to the NYCDOHMH School Health Vision Program, highlighting the collaboration between the New York City Department of Health and Mental Hygiene and the Department of Education to ensure children receive the necessary support for their vision health.

QuestionAnswer
Form NameForm E12S Dohmh Doe
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namese12s form, 28TH, e12s form doe, OSIS

Form Preview Example

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

(Please print on hard surface)

*OSIS #

____ ____ ____ – ____ ____ ____ – ____ ____ ____

CHILD’S LAST NAME:

CHILD’S FIRST NAME:

DATE OF BIRTH

SCHOOL #

DISTRICT

BOROUGH

GRADE/CLASS

SEX: Male

Female

*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?

 

 

 

 

 

 

Uncorrected

 

Corrected

 

 

 

 

Far

Near

Far

Near

Right

Left

Both

Prescription given:

Sphere

Cylinder

Axis

Add

Right

Left

PD

School accommodations requested:

Special vision services recommended? Yes No If yes, describe

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

Any front seat

 

Blackboard

 

Front left

Front center

Front right

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)