Screening Feedback

Thank you for providing this information.

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After your child's vision screening we had told you that a potential problem was indicated and that the child should be seen by an eye care professional for confirmation. Please use this form to let us know if the child received follow-up care and what has happened since. Please note: An answer is required for every question.

Name(Required)

Name of person submitting information

Child Screened(Required)

First name and last initial of child who had been screened.

County(Required)

Select the county where you live.

Screening Site(Required)

Where did the vision screening occur? (i.e. name of child's school, daycare center, church, etc.)

Examined(Required)

Was the child seen by an eye care professional?

Yes

Results / Comments(Required)

Please let us know what the doctor said, or let us know if there is anything else you'd like to share.