Eye Report Form For Children With Visual Problems
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Georgia Department of Education
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CONFIDENTIAL
Eye Report for Children with Visual Problems
Dear Eye Care Professional:
To determine if a student meets Georgia eligibility for visual impairments, an eye report must be
completed by an ophthalmologist/optometrist or possibly a neurologist in the case of cortical
visual impairment. If eligible, the student may also qualify for American Printing House for the
Blind (APH) funds. Each year on the first Monday in January, the State of Georgia conducts a
count of students who are legally blind to access federal quota money in order to buy braille and
large print books and other accessible instructional materials. It is critical that we get an
accurate count of the legally blind students in the state, including students who are legally blind
who have other disabilities, that make it challenging to obtain a standard Snellen acuity. For our
purposes, legally blind is defined as a visual acuity of 20/200 or less in the better eye after best
correction or a visual field restricted to less than 20 degrees in the better eye. Some students
may qualify for vision impaired services with a visual field restriction of greater than 20 degrees
and an acuity greater than 20/200. This form is designed to determine if a student meets this
criterion. Thank you for taking the time to complete this form.
Student Name_________________________________________ Date of Birth______________
Local School System___________________Date of most current eye exam:________________
Ocular Diagnosis: _______________________________________________________________
Will this ocular diagnosis result in a progressive vision loss? YES
NO
Prognosis & Recommendation(s):__________________________________________________
I.Acuities (If unable to obtain Snellen Acuity, please complete section III.:
Distance
Near Reading
If CF, state distance
(ft.)
Distance (in.)
O.D.
O.S.
O.U.
O.D.
O.S.
O.U.
O.D.
O.S.
O.U.
(1) Without Correction
(2) With Correction
II. Measurement of Field of Vision:
Is there any abnormality or limitation in the field of vision? YES
NO
If YES, what is the widest diameter in the remaining field?
OD_________________
OS _________________
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