Spot Vision Screener Documents
As of January 8, 2015 Version 2 of the HSB OKS Operations Manual is now available. This will replace Version 1 which was released on August 26, 2014. The major changes are a result of acquiring 15 more Spots thanks to the LCIF grant we received. We now have an online reservation system for each Zone that has a HSB Spot to make it easy to see what dates are available and to request specific dates for screenings. There were minor changes to many of the forms with a major change to the Spot Transfer Form. This form allows the transfer of a Spot form between a Zone Coordinator to a club or a transfer between two clubs. It is recommended you download the PDF of the new manual and a zip file of the forms so you can start using them. You can do that by clicking on the following:
Once you have downloaded all the forms you can at a later date download a single form below.
1. Club Planning Template - A template that each club can use as a starting point to create their own yearly vision screening plan. The template is in Microsoft Word format with links to online resources to (e.g. NH schools and Daycare Centers)
2. Vision Screening Important for Young Children - Vision Screening overview to be used when meeting with Site Coordinators (e.g. School Nurses and Daycare Directors)
1. Consent Form – Every child screened needs to have a Consent Form is signed by their parent/guardian. This is customizable by each club to include name of club, screening date and contact information.
2. Screening Results Letter Option A - Letter to be distributed to parents along with the printout of the screening results. One letter covers either a referral or no referral.
3. Screening Results Letter Option B - Letter that can be customized to add local Optometrists and Ophthalmologists.
4. Vision Screening Summary - Samples of screening results from the Spot - one for Screening Complete, Complete Eye Exam Recommended and Screening Flagged
5. USB Drive Instructions - An instruction sheet for Site Coordinators on how to load the USB drive with the children to be screened.
6. Manual Screening Sheet - Used to keep track of people screened when the USB drive approach is not able to be used. Primarily used for Public and Other Events.
7. NH Background Check - Background Checks using State of NH forms
8. Spot Usage Transfer Form - This is an agreement between two entities (OKS Zone Coordinator and/or Club) on the transfer of the Spot Kit. This form includes a checklist of all the items contained in the Spot Kit and verification everything is in working order.
1. Screening Event Checklist – A one page summary of the key steps needing to be done for a Screening Event.
2. Screening Event Summary 44N - A summary of the screening event with the # of children screened, # referred, event, club, etc. that will be sent to the District
3. Screening Event Summary 44H - A summary of the screening event with the # of children screened, # referred, event, club, etc. that will be sent to the District
4. Lions Coloring Page - A file that can be printed and handed out as a reward for children that have been screened.
Thank You Letter - Letter to Site Coordinators thanking them for arranging the screening(s), reminding them of following up on referrals.