Vision and Hearing Screening Request
Date
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Please administer the Vision and Hearing tests, as the following student has been referred for special education testing:
Student Name:
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Teacher Name:
*
Grade:
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Please Select
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Comments:
**Please return the results to me within one week.
Date of Vision Test:
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Results of Vision Test:
Date of Hearing Test:
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Results of Hearing Test:
Comments:
Nurse's Signature
Date of Signature
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Submit
Should be Empty: