Illinois requires proof of an eye examination for children entering an Illinois school for the first time, and this two-page IDPH report is that proof. An optometrist or a physician who provides eye exams, such as an ophthalmologist, records case history, visual acuity, exam findings, diagnosis and classroom recommendations. The parent submits it to the school no later than October 15 of the year the child is first enrolled.
The parent or guardian fills in the student's identifying data and signs the consent on page 2 releasing the results to school or health authorities. The examining doctor (MD, OD or DO) completes every part headed 'To Be Completed By Examining Doctor' and signs with a license number.
The parent or guardian enters the student's last name, first name and middle initial, birth date, gender and grade, the parent or guardian's name and phone, the student's street address, city and ZIP code, and county. The instructions above these fields explain that the report must reach the school by October 15 of the year the child first enrolls and that a parent unable to obtain an exam must submit a waiver.
Record the date of exam, then ocular history and medical history as Normal or Positive for a stated finding, and drug allergies as NKDA or Allergic to a named drug, with a line for other information. The exam date must fall within one year before the first day of the school year in which the child enters an Illinois school for the first time.
Enter uncorrected and best corrected visual acuity as 20/ values for distance in the right eye, left eye and both eyes, and for near with both eyes. Then answer Yes or No to whether refraction was performed with dilation. If the child could not read a chart, the findings grid below lets you mark the relevant test 'Not Able to Assess' and explain in Comments.
Mark each line: external exam (lids, lashes, cornea), internal exam (vitreous, lens, fundus), pupillary reflex, binocular function (stereopsis), accommodation and vergence, color vision, glaucoma evaluation, oculomotor assessment and other. Use Comments for detail. The printed note limits 'Not Able to Assess' to a child who cannot complete the test, not a test the doctor could not provide.
Check normal, myopia, hyperopia, astigmatism, strabismus or amblyopia, and use the Other line for any further diagnosis. The diagnosis closes page 1, which ends with 'Continued on next page'; page 2 repeats the 'To Be Completed By Examining Doctor' heading and turns the findings into recommendations for the school.
Item 1 asks whether corrective lenses are needed and, if so, for constant wear, near vision or far vision, and whether they may be removed for physical education. Item 2 asks whether preferential seating is recommended, with comments. Item 3 sets re-examination at 3, 6 or 12 months or another interval. Lines 4 and 5 are blank for further recommendations to the school.
Enter your license number, address, printed name and phone, check MD, OD or DO, then sign and date. The report is valid proof only when signed by an optometrist or a physician who provides eye examinations, which is the requirement stated at the top of page 1.
The parent or guardian signs and dates a statement agreeing to release the information on the form to appropriate school or health authorities. The consent sits at the very bottom of page 2, below the examiner's signature block, so check that the parent has signed and dated it before the report goes to the school.
Download the current version from the source each time; forms change without notice.
State of Illinois Eye Examination Report
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.
Sources for this guide
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Proof of the exam must reach the school no later than October 15 of the year the child is first enrolled in an Illinois school, or when the school requires it for other children. The exam itself must be completed within one year before the first day of that school year.
An optometrist or a physician who provides eye examinations, such as an ophthalmologist. The signature block asks for the examiner's printed name, an MD, OD or DO checkbox, license number, address, phone, signature and date. The parent or guardian signs separately to consent to releasing the information to school or health authorities.
The form's note says 'Not Able to Assess' refers to the child being unable to complete a test, not to the doctor being unable to provide it. Each examination line (external, internal, pupils, stereopsis, accommodation and vergence, color vision, glaucoma evaluation, oculomotor and other) also has a Comments column for details.
Yes. IDPH posts a Spanish version of the report alongside the English one on its Vision and Hearing page, both from the May 2026 printing. The Eye Examination Waiver is also posted in English and Spanish for parents who cannot obtain an exam.