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Resources for Screenings

New? column shows YES for 6 months after Revised date

Screening Protocol PDFs:

MD5M has established protocols that MUST be followed when doing Kidsight screenings. Please review the documents below to make sure you are operating in compliance with these protocols.

New?RevisedDocument
 2018-02 Screening Protocol
 2017-09 Data Entry and Security
 2020-10-01 COVID-19 Policies and Procedures
 2020-10-02 COVID-19 Liability Waiver Lion
 2020-10-02 COVID-19 Liability Waiver Location

English Language Forms

The Word files have places where you fill in information (club name, screening date & location, etc) before printing. The places where you need to insert your information are indicated by blue text. Just click on the blue text, and it will be "selected" so you can type in your information. Then print the number of copies needed.

Clicking on the links will open the Word documents in another window of your browser.
Or use "Right Click" on the link, then choose "Save Link As" to save the file to a folder of your choice.

The PDF files are printable forms with lines where you hand write information.

New?RevisedDocument
 2018-05-01 Letter to Pre-School     Word file
YES2021-11-29 Cover Letter to Parents     Word file
YES2021-06-02 Parent Consent Form     Word file
YES2021-10-11 Results Letter to Parents: Not Referred     Word file
YES2021-10-11 Results Letter to Parents: Referred     Word file
 2021-04 Photo Release Form - Minor     PDF
 2021-04 Photo Release Form - Adult     PDF
 2019-03 Vision Screening Information     PDF

Chinese Language Forms

New?RevisedDocument
 2019-03 Cover Letter to Parents
 2021-02-01 Parent Consent Form
 2019-03 Results Letter to Parents: Not Referred
 2019-03 Results Letter to Parents: Referred
 2021-05 Photo Release Form - Adult

Hmong Language Forms

New?RevisedDocument
 2019-04 Cover Letter to Parents
 2019-04 Parent Consent Form
 2019-04 Results Letter to Parents: Not Referred
 2019-04 Results Letter to Parents: Referred

Somali Language Forms

New?RevisedDocument
 2019-03 Cover Letter to Parents
 2019-03 Parent Consent Form
 2019-03 Results Letter to Parents: Not Referred
 2019-03 Results Letter to Parents: Referred

Spanish Language Forms

New?RevisedDocument
 2021-03 Cover Letter to Parents
 2021-03 Parent Consent Form
 2021-03 Results Letter to Parents: Not Referred
 2021-03 Results Letter to Parents: Referred
 2021-03 Could Not Screen Letter

Follow Up Reports

These reports are required of all screenings, and are a requirement of our receiving the LCIF and MLVF grants used to purchase equipment. No individually identifiable data is required, but ages and number of children screened is needed, as is follow up status of all children referred for consultation with an eye care professional.

New?RevisedDocument
 2019-09 Screening Team Site Report
 2018-02 Screening Team Site Report Addendum     (Report for children over 6 years old).
YES2021-10-27 Indicator Site Report
 2018-04 Screening Follow Up Report

Camera Specific Instructions

These documents were created by Lion Lori Klein (5M2) for the Plus Optix Camera

New?RevisedDocument
 2017-08-21 How To Pre-Enter Data To The Plus Optix Camera
 2017-08-21 Sample Spreadsheet for Pre-Entering Data To Plus Optix Camera (.csv file)
 2017-08-21 How To Print Referral PDFs From The Plus Optix Camera
 2017-08-21 How To Delete Data From The Plus Optix Camera After Screening

Download our Logo

Click on the link to put the file in your Download folder.
Or use "Right Click" on the link above, then choose "Save Link As" to save the file to a folder of your choice.


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