LINCOLN PARK PUBLIC SCHOOLS
DEPARTMENT OF SPECIAL SERVICES

VISION/EYE REPORT

Name: ______________________________________________________________________Date of Birth:_________________________

Address: _______________________________________________________________________________________________________________

Home Phone: _________________________Child’s School: ________________________________District: _____________________________

I.Date of Examination: ____________________________

II.Measurements:

A.Corrected Visual Acuity – Expressed in numbers

Distant VisionNear Vision

Right eye (O.D.)______________________________________

Left eye (O.S.)  _______________________________________

Both eyes (O.U.)_______________________________________

B.If child is too young to measure vision by Snellen chart or letter matching, use the following statement:

Based on other examination findings, best determination at this time indicates vision is less than 20/70:  Yes_______No___
____
Is s/he considered to be legally blind?  Yes_______No_______

C.Field of Vision:  Is there a limitation?  ________________ What is the widest diameter (in degrees of the remaining visual field?   O.D. _________O.S. _________

D. Is there impaired color perception? __________________ If so, for what color (s) ___________________

III.Diagnosis and Eye Surgeries:________________________________________________________________

_________________________________________________________________________________________

IV.Prognosis and Recommendations:

A.Is pupil’s vision impairment considered to be:  Able to improve  ____________Stable _______________
Deteriorating ______________  Uncertain ______________

B. What treatment is recommended, if any _____________________________________________________

C.When is re-examination recommended? _____________________________________________________

D.Glasses:  Not needed _____ To be worn constantly ______________ for close work only _____________
Other: (specify) __________________________________________________________________________

E.Physical Activity:  Unrestricted _____________________________________________________________
Restricted, as follows: _____________________________________________________________________

F.Additional Information: ___________________________________________________________________
_________________________________________________________________________________________

Please forward to:Name of examiner:________________________________

Address:____________________________________



Visually Impaired Department            ____________________________________
Special Education Services
Lincoln Park Public SchoolsPhone Number: ____________________  Fax:  __________________
2800 Lafayette St. Rm 112
Lincoln Park, MI  48146Case Number: ______________________ Date: __________________
Phone: (313) 389-0210
Fax: (313) 389-0752Signature: _________________________________