Pg. 1-5 EYE EXAM REPORT FOR INDIVIDUALIZED EDUCATION PROGRAM (IEP) Instructions after doctor completes this form: Retain a copy in the patient file Fax to the attention of: Shawn Heimlich, Director of Special Services 614-873-0845 Or mail to: JA Special Services Office 6440 Kilbury-Huber Rd. Plain City, OH 43064 Doctor, please note NA (not applicable) beside any item below that is not included in your routine examination. Name of Student Name of School Parent/Guardian DOB Grade Exam OBJECTIVE FINDINGS A. Visual Acuity At Distance At Near Without Rx: (R) 20/ (L) 20/ (R) 20/ (L) 20/ With Old Rx: With New Rx: No Rx B. Cover Test Distance Old Rx New Rx Near C. Binocular Status/Efficiency Add remarks when ABNORMAL is checked. Near point of convergence Ocular motility (eye movement accuracy: ductions/versions Ability to maintain focus at near (amplitude) Binocular alignment distance (eye teaming at near) Binocular alignment near (eye teaming at near) Binocular depth perception (stereopsis)
Pg. 2-5 D. Color Perception DIAGNOSIS Convergence problems (R) (L) Accommodation problems (R) (L) Amblyopia Diagnosis (R) (L) Refractive Diagnosis Myopia (nearsighted) (R) (L) Hyperopia (farsighted) (R) (L) Astigmatism (R) (L) Emmetropia (no correction) (R) (L) NONE Ocular Health Diagnosis ---External Exam Diagnosis ---Fundus Exam Diagnosis Binocular Diagnosis Diagnosis Add remarks when ABNORMAL is checked Recommendations/Recommended Treatment No treatment indicated Present corrective lenses are satisfactory New corrective lenses have been recommended Remarks: A program of amblyopia treatment has been implemented Eye drops (R) (L) Patching (R) (L) Other Explain:
Remarks: Pg. 3-5 Return to this office for further care on (date) Further evaluation? (if yes, indicate what additional care is needed) CORRECTIVE LENSES SHOULD BE WORN Constantly Near Only Desk Work Computer Classroom Distance Only Sports Remarks: Special Recommendations for Classroom Interaction Please check which applies O.D. D.O. Signature M.D. Eye Care Provider Address Phone Instructions after doctor completes this form: Retain a copy in the patient file Fax to the attention of: Shawn Heimlich, Director of Special Services 614-873-0845 Or mail to: JA Special Services Office 6440 Killbury-Huber Rd. Plain City, OH 43064
Pg. 4-5 HIPPA INFORMATION RELEASE FORM As parent or guardian of the student named above, I authorize the eye care provider list to disclose (by mail or by facsimile) the results of the HB95 Eye Exam Report for IEP to my child s school: School Address City State Zip Phone Fax The purpose of disclosing the Eye Exam Report is for use in connection with my child s Individualized Education Plan (IEP). I understand that while in possession of authorized school personnel, the Eye Exam Report is not covered by HIPPA. Instead, it is an education record, whose privacy, use and disclosure is protected by the Family Educational Rights and Privacy Act. (FERPA) I understand that my refusal to sign the Authorization will not affect my child s ability to obtain treatment from the eye care provider listed above. I understand my right to inspect or copy information disclosed by this Authorization. I understand I may revoke (cancel) this authorization at any time. Revocation must be in writing. The eye care provider cannot be held responsible for having disclosed information in reliance of this Authorization before receiving a written revocation. I release the eye care provider from legal liability for disclosing The Eye Exam Report (and Protected Health Information contained in it) as authorized by my signature below. This Authorization will expire on: Or Event Signature of Parent or Guardian Print Name
Pg. 5-5 EYE EXAM PORTION OF HB 95 Section 41.36 (A) In the 2004-2005 and 2005-2006 school years, within three Pg. months 4-5 after a student identified with disabilities begins receiving services for the first time under an individualized education programs, as defined in section 3323.01 of the Revised Code, the school district in which that student is enrolled shall require the student to undergo a comprehensive eye examination performed either by an optometrist licensed under Chapter 4725. of the Revised Code or by a physician authorized under Chapter 4731. of the Revised Code to practice medicine and surgery or osteopathic medicine and surgery who is comprehensively trained and educated in the treatment of the human eye, eye disease, or comprehensive vision services, unless the student underwent such an examination within the nine-month period immediately prior to being identified with disabilities. However, no student who has not undergone the eye examination required under this section shall be prohibited from initiating, receiving, or continuing to receive services prescribed in the student s individualized education program. (B) The superintendent of each school district or the superintendent s designee may determine fulfillment of the requirement prescribed in division (A) of this section based on any special circumstances of the student, the student s parent, guardian or family that may prevent the student from undergoing the eye examination prior to beginning special education services. (C) Except for a student who may be entitled to a comprehensive eye examination in the identification of the student s disabilities, in the development of the student s individualized education program, or as a related service under the student s individualized education program, neither the state nor any school district shall be responsible for paying for the eye examination required by this section. District Designee s Signature Parent/Guardian Signature Cc: Student File Parent/Guardian Multifactor Evaluation