home

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?	Revised	Document
	2018-02	Screening Protocol
	2022-12-01	Data Entry and Security

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?	Revised	Document
	2022-03-08	Letter to Pre-School Director Word file
YES	2024-04-16	Lions Letter to Parent Word file
YES	2024-04-08	Director Letter to Parents Word file School Director perspective
	2024-03-05	Director Letter to Parents w/Opt-Out paragraph Word file School Director perspective
	2022-05-24	Parent Consent Form Word file
	2023-01-26	Results Letter to Parents: Not Referred Word file
	2023-12-07	Results Letter to Parents: Referred Word file
	2022-05-24	Screening Site Worksheet PDF Can be used for notes during a screening.
	2021-04	Photo Release Form - Minor PDF
	2021-04	Photo Release Form - Adult PDF
	2019-03	Vision Screening Information PDF
	2022-08	MD5M Lions Kidsight Readiness Report 2022 Fillable PDF

Chinese Language Forms

New?	Revised	Document
	2022-11-13	Lions Letter to Parent Word file
	2022-05-24	Parent Consent Form Word file
	2023-01-26	Results Letter to Parents: Not Referred Word file
	2023-12-07	Results Letter to Parents: Referred Word file
	2019-03	Vision Screening Information PDF
	2021-05	Photo Release Form - Minor
	2021-05	Photo Release Form - Adult

French Language Forms

New?	Revised	Document
	2022-11-13	Lions Letter to Parent Word file
	2022-11-02	Director Letter to Parents Word file School Director perspective
	2022-05-24	Parent Consent Form Word file
	2022-06-12	Results Letter to Parents: Not Referred Word file
	2023-12-07	Results Letter to Parents: Referred Word file
	2019-03	Vision Screening Information PDF

Hmong Language Forms

New?	Revised	Document
	2022-11-13	Lions Letter to Parent Word file
	2022-05-24	Parent Consent Form Word file
	2023-01-26	Results Letter to Parents: Not Referred Word file
	2023-12-07	Results Letter to Parents: Referred Word file
	2019-03	Vision Screening Information PDF

Somali Language Forms

New?	Revised	Document
	2022-11-14	Lions Letter to Parent Word file
	2022-05-24	Parent Consent Form Word file
	2023-01-26	Results Letter to Parents: Not Referred Word file
	2023-12-07	Results Letter to Parents: Referred Word file
	2019-03	Vision Screening Information PDF

Spanish Language Forms

New?	Revised	Document
	2022-11-13	Lions Letter to Parent Word file
	2022-05-24	Parent Consent Form Word file
	2023-01-26	Results Letter to Parents: Not Referred Word file
	2023-12-07	Results Letter to Parents: Referred Word file
	2019-03	Vision Screening Information PDF

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?	Revised	Document
	2022-10-18	Screening Team Site Report
	2022-10-18	Screening Follow Up and Indicator Report
	2022-06	Screening Follow Up Form (This form is for parents).

Camera Specific Instructions

These documents were created by Lion Lori Klein (5M-2) and Lion Larry Stryker (5M-1) for the Plusoptix Camera.

New?	Revised	Document
	2023-01-30	How To Enter Data Into a Plusoptix Camera
	2023-01-30	Sample File For Entering Data To Plusoptix Camera (EXAMPLE OPTION i.csv file)
	2023-01-30	Sample File For Entering Data To Plusoptix Camera (EXAMPLE OPTION ii.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.