Vision Screening Results Log
Record and track vision screening outcomes for individuals.
Participant Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Other
Screening Date
*
-
Month
-
Day
Year
Date
Screening Location
*
Screener's Name
*
First Name
Last Name
Visual Acuity Results
*
Rows
Right Eye (OD)
Left Eye (OS)
Distance (e.g., 20/20)
Near (e.g., 20/20)
Color Vision Test Result
*
Normal
Deficiency Detected
Not Tested
Observations / Comments
Follow-up Recommendation
*
No follow-up needed
Monitor/Rescreen
Refer to specialist
Parent/Guardian Email (if participant is a minor)
example@example.com
Submit Screening Log
Should be Empty: