Submit Vision Screening Results - Prevent Blindness Wisconsin

Prevent Blindness Wisconsin thanks you for sharing your vision screening results. These results help us to evaluate our vision screening protocols and create vision health resources for families across Wisconsin.

Please contact [email protected] or 414-765-0505 if you have any questions or concerns.

Thank you for making the vision health of children across Wisconsin a priority.

Vision Screening Results Submission

Agency/School District/Employer*
Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Email*
Phone
County in Wisconsin*
Date(s) of Vision Screening
Grades/Ages Vision Screened*
Vision Screening Tool(s) used
Assistance from Lions Club? Add club name if yes
Vision Screening Results*
Grade/Age Number Screened Number Referred Results/Diagnoses
Results
Grade/Age Myopia Hyperopia Astigmatism Amblyopia Glasses No information Additional Diagnoses
Total Results*
Total Screened Total Referred
Vision Health Education Provided
Number Reached with Vision Health Education
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Additional Notes or Comments
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Grade/Age	Number Screened	Number Referred	Results/Diagnoses

Grade/Age	Myopia	Hyperopia	Astigmatism	Amblyopia	Glasses	No information	Additional Diagnoses

Total Screened	Total Referred