Form Dch-0479 - Kindergarten Entry/preschool Hearing/vision Screening Record - Michigan Department Of Community Health
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1MICHIGAN DEPARTMENT OF COMMUNITY HEALTH
County
Screening Location
MEDICAID: Y
N Number:
KINDERGARTEN ENTRY/PRESCHOOL HEARING AND VISION SCREENING RECORD
CHILD’S NAME _________________________________________ Male Female DOB __________________AGE ____________
Name Used ______________________________________________ School Attending ____________________________________
Primary Care Provider____________________________________ Provider phone______________________________________
PARENT/GUARDIAN’S NAME _________________________________ Telephone ______________________________ H/W/C
Address _________________________________________________ City ________________________________ Zip ____________
BRIEF HISTORY
HEARING
1. Has your child been seen by a doctor for any ear problems?
Y
N
Date of Exam _____________ Doctor _____________________
2. Is your child on any cold or allergy medications?
Y
N
3. As a parent, do you have any concerns regarding your child’s hearing?
Y
N
VISION
1. Has your child ever been examined by an eye doctor?
Y
N
Date of Exam _____________ Doctor _____________________
2. Has your child ever confused colors?
Y
N
3. When your child is ill or tired, do the eyes appear crossed or
does one eye wander when looking at an object?
Y
N
DO NOT WRITE BELOW THIS LINE
HEARING SCREENING
RESULTS
Screening
Pass
Fail
□ Pass
Threshold
Pass
Fail
□ Refer
Audiogram
□ Under Care
□ Retest
VISION SCREENING
RESULTS
1. Visual Acuity/2-Line Difference (LEA Symbols Cards)
□ Pass
20/40
20/25
□ Refer
Both eyes
0 1 2 3 4 5 6
□ 2-Line
Right eye
0 1 2 3 4 5 6
0 1 2 3 4 5 6
□ 20/50
Left eye
0 1 2 3 4 5 6
0 1 2 3 4 5 6
□ Symptom
□ Fail; no refer
2. Stereo Butterfly
Pass
Fail
□ Under Care
□ Permanent
Difficulty
□ Retest
3. Eye History
Pass
Fail
4. Symptom(s): ________________________________________
Pass
Fail
ATTENTION PARENT(S): Your child was given the health department hearing and vision screening tests:
Hearing
Vision
□ Passed
□ Passed
□ Failed (an examination by your local health department
□ Failed (an eye examination by an ophthalmologist
or your doctor is required)
or optometrist is required)
Please present this certificate when enrolling your child in school for the first time (Michigan Public Health Code; Act
368 or 1978). Retain this statement with other health records of your child.
______________________________________________________________________________________________________________
Child’s Name
Date of Screening
Qualified Hearing/Vision Technician
______________________________________________________________________________________________________________
Health Department
DCH-0479 (8/2014)
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