Nebraska requires a visual evaluation for students entering school at the beginner grade, kindergarten or first grade, and for transfers from out of state into any grade (Neb. Rev. Stat. 79-214). This convenience form lets the examiner certify the evaluation and report pass or fail results, distance and near acuity, and any recommendation for further evaluation.
The examiner (physician, PA, APRN or optometrist) completes Part I with the results and signs it. The parent or guardian completes Part II, consenting to release the information to the named school.
Download the current version from the source each time; forms change without notice.
Report of Visual Evaluation
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.
Under Neb. Rev. Stat. 79-214, students entering school at the beginner grade (kindergarten or first grade) and students transferring from out of state into any grade need a visual evaluation. FH-41 is a convenience form for documenting it.
No specific form is required by the statute. FH-41 is provided as a convenience for the family and the child's health care provider, and the information may be shared with school personnel to promote the child's safety and educational success.
Yes. Nebraska DHHS posts fillable English and Spanish versions of the Report of Visual Evaluation on its school health forms page, next to the physical examination report and certification forms.