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SECTION 400 PART B: FORMS FOR SCREENINGS

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REVISED: 01/25/10

DSB-2007: EVALUATION WITH VIDEO MAGNIFICATION (CLOSED CIRCUIT TELEVISION)

DSB-2007, Evaluation with Video Magnification (Closed Circuit Television)

DSB-2007, Evaluation with Video Magnification (Closed Circuit Television) Instructions

DSB-2207 VISION SCREENING LIST

PURPOSE

The Nursing Eye Care Consultant completes this form at the time of the vision screening. It is used primarily when children are being screened at Head Start, day care or school. It provides a source for statistical information for the Agency as well as a log for the NECC to record follow-up services.

INSTRUCTIONS

DSB-2207, Vision Screening List

DSB-2218 PERMISSION FORM FOR VISION SCREENING AT DAY CARE

PURPOSE

A permission form must be signed by the parent(s) of a child before the Nursing Eye Care Consultant can screen the child at a day care center. This form should be provided to the Director of the day care center for distribution to the parent(s) before the date of the screening. The NECC will collect the forms from the Director before the screening begins.

INSTRUCTIONS

DSB-2218, Permission Form for Vision Screening at Day Care

DSB-2220 REPORT TO PARENTS OF CHILD SCREENED AT DAY CARE

PURPOSE

This form should be sent to the parent(s) of a child who did not have a normal vision screening when the Nursing Eye Care Consultant screened the child at a day care center. It provides information about the reason the NECC is concerned about the child’s vision and urges the parent(s) to take the child for a thorough eye examination. An eye care provider can then use it as a reporting document to return to the NECC.

INSTRUCTIONS

DSB-2220, Report to Parents of Child Screened at Day Care

DSB-2205-A REFERRAL FOR LOW VISION SCREENING

PURPOSE

DSB-2205 is used to refer the consumer to the Nursing Eye Care Consultant for low vision screening. The form will capture the consumer’s identifying information and provide additional information to the NECC which will be of assistance in doing a thorough evaluation of low vision needs.

PREPARED BY

DSB-2205 is prepared by the Social Worker for the Blind, the Independent Living Rehabilitation Counselor or the Rehabilitation Counselor when there is a need to refer the consumer to the NECC. It should be prepared in duplicate with original being sent to the NECC and a copy will remain in the case record.

INSTRUCTIONS

NAME:

Enter consumer’s full name.

ADDRESS

Enter consumer’s full address, including city & zip.

COUNTY:

Enter consumer’s county of residence.

ELIGIBILTY INFROMATION:

Enter if consumer is Needs or Non-Needs.

DOB:

Enter consumer’s month, day and year of birth.

TELEPHONE:

Enter consumer’s area code and telephone number

ALTERNATE #

Enter a work phone # or that of a friend or relative where consumer can be reached

CONTACT PERSON:

Enter a name of a friend or relative.

LIVING SITUATION:

Indicate whether consumer lives alone or with family or friends.

REASON FOR REFERRAL

Enter the consumer's current need for low vision aids..

DIRECTIONS:

Enter good, clear driving directions from the county DSS or from the NECC's office. Specify the starting point of the directions

EDUCATION:

Enter grade completed in school.

OCCUPATION:

Enter current occupation if there is one.

TRAINING:

Enter any special training the consumer has received.

Enter experience from past employment

WORK EXPERIENCE:

Enter any special training the consumer has received.

Enter experience from past employment

VISUAL ACUITY:

Enter right eye visual acuity beside OD.

Enter left eye visual acuity beside OS.

VISUAL FIELD:

Enter right eye visual field beside OD.

Enter left eye visual field beside OS

VISUAL DIAGNOSIS:

Enter the eye diagnosis from client's eye doctor and also attach an eye report.

PERTINENT MEDICAL PROBLEMS / IMPAIRMENT / COMMENTS:

Enter any additional physical or visual concerns which may be pertinent information for the NECC in assessing the low vision needs of the consumer

CASE MANAGER SIGNATURE

The signature of the case manager who is referring the consumer to the NECC (This can be the SWB, IL Rehabilitation Counselor, or the Rehabilitation Counselor).

DATE OF REFERRAL:

Enter the date that the case manager is completing the form.

DSB- 2205-A, Referral for Low Vision Evaluation

DSB-2205-B REPORT ON LOW VISION SCREENING

LOW VISION SCREENING:

NECC should indicate findings on visual acuity and any consumer complaints and/or comments. If NECC finds that consumer needs or requests a referral to a low vision specialist from which consumer may make a selection. Low vision aids recommended should be listed in order of priority with recommendations being limited to two (due to limited funds) unless there are extenuating circumstances. Additional aids suggested can be listed in SUMMARY.

SUMMARY:

The date of initial contact should be listed. This can be the date of first written contact by NECC which often explains that referral has been received and telephone contact by NECC will follow shortly for scheduling an appointment.

NOTES REGARDING VISIT:

NECC should elaborate on the low vision evaluation, whether it appears consumer is a good candidate for low vision aids. The date of the evaluation as well as the NECC Signature should be completed.

FOLLOW-UP OF EVALUATION:

NECC should document later contact with consumer to determine whether low vision aids have proved to be helpful. If further training is needed, then this should be indicated as well as NECC’s plans to meet this need.

DSB-2205-B, Report on Low Vision Evaluation

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