Certificate Of Vision Screening Form
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1
2Iowa Department of Public Health
CERTIFICATE OF VISION SCREENING
RETURN COMPLETED FORM TO CHILD’S SCHOOL.
Student Information (please print)
Student Last Name:
Student First Name:
Birth Date (M/D/YYYY):
Parent/Guardian Telephone Number:
Student Address:
Zip Code:
Screening Information (vision screening provider must complete this section or parents may attach a
copy of vision screening results given to them by a provider.)
Date of Vision Screening:
________________________________
Results (visual acuity):
Right Eye__________
Left Eye__________
Overall Result (Please select one):
Referral to eye health professional (Please select one):
Pass or
Fail
Yes or
No
Screening Provider:
Provider Business Name/Source of Screening:
(please print)
Provider Name:
Phone:
(please print)
Signature and Credentials
of Provider:
Date:
A parent or guardian of a child who is to be enrolled in a public or accredited nonpublic elementary school
shall ensure the child is screened for vision impairment at least once before enrollment in Kindergarten and
again before enrollment in the 3
rd
grade.
To be valid, a minimum of one child vision screening shall be performed no earlier than one year prior to the
date of enrollment in Kindergarten and no later than six months after the date of the child’s enrollment in
Kindergarten.
To be valid, a minimum of one child vision screening shall be performed no earlier than one year prior to the
rd
rd
date of enrollment in 3
grade and no later than six months after the date of the child’s enrollment in 3
grade.
RETURN COMPLETED FORM TO CHILD’S SCHOOL.
−
Iowa Department of Public Health
B u reau of Family Health
321 E 12th Street - Des Moines, IA 50319
−
Phone 800-383-3826
FAX 515-725-1760
12/14/2015
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