Vision and Hearing Screening Form
Students Name
*
School
*
Vision Screening Date
*
/
Month
/
Day
Year
Date
Administered By
*
Results
*
Referral to a Doctor
*
Yes
No
Hearing Screening Date
*
/
Month
/
Day
Year
Date
Administered By
*
Results
*
Referral to a Doctor
*
Yes
No
Other
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