Illinois vision screening programs send this report home when a child is referred after a screening at school or another testing location. The screener records which tests were given and why the child was referred, then the examining eye doctor completes the lower half with acuity, diagnosis and classroom recommendations so the school knows what was found and what to adjust.
The screening technician fills in the test, referral and symptom boxes, and the parent or guardian signs consent to release the results to school or health authorities. The examining optometrist or ophthalmologist completes and signs the section marked 'To be completed by examining doctor.'
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Vision Examination Report
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Two people share it. The vision screener records the instrument used, the tests given (visual acuity, plus sphere, muscle balance, near and far binocular vision), the reason for referral and any symptoms. The optometrist or ophthalmologist who examines the child then completes the examining doctor section and signs it.
No. The V-4 is the follow-up report for a child referred by a vision screening program. The State of Illinois Eye Examination Report is a separate form, so a family may be asked for one or both depending on why the school needs the information.
The doctor can check that close work may be difficult or cause fatigue, that preferential seating is needed, that glasses may be removed for physical education, and whether re-examination is advised in six months, twelve months or another interval.