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
	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?	Revised	Document
YES	2022-03-08	Letter to Pre-School Director Word file
	2021-11-29	Cover Letter to Parents Word file
YES	2022-06-12	Cover Letter to Parents - Alternate Word file School Director perspective
YES	2022-05-24	Parent Consent Form Word file
YES	2022-06-12	Results Letter to Parents: Not Referred Word file
YES	2022-06-12	Results Letter to Parents: Referred Word file
YES	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

Chinese Language Forms

New?	Revised	Document
	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?	Revised	Document
	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?	Revised	Document
	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?	Revised	Document
	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?	Revised	Document
YES	2022-06-23	Screening Team Site Report
		Screening Team Site Report Addendum (This report is no longer used).
YES	2022-06-23	Screening Follow Up and Indicator Report
YES	2022-06	Screening Follow Up Form (This form is for parents).

Camera Specific Instructions

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

New?	Revised	Document
	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.