forma de referencia de vision - East Whittier City School District

forma de referencia de vision - East Whittier City School District

EAST WHITTIER CITY SCHOOL DISTRICT
14535 E. Whittier Blvd., Whittier, CA 90605
(562) 907-5900 FAX (562) 945-6062
Forma De Referencia De Visión
Nombre de Alumno/a:
Escuela:
Fecha:
Estimados Padre/Guardián:
Según el resultado del examen de visión de la escuela, su niño/a necesita un examen de visión completo. Dele
atención apropiada lo mas pronto posible. Por favor, lleve esta forma al examinador para que la firme y regrese esta
forma completa a la escuela. Si hay una necesidad monetaria, por favor llame a la enfermera para mas
información.
Enfermera de Escuela
NOTE TO EXAMINER:
We have directed the parent/guardian’s attention to the need for a complete examination because of:
Performance on Snellen Test
R 20/
L 20/
B 20/
Signs and Symptoms
The school would appreciate a report from you and any recommendations you desire to make. This information will
be of help in planning the education program for this pupil.
REPORT OF EXAMINER TO THE SCHOOL
Visual Acuity
Glasses
Without Lenses
With Lenses
R 20/
Both 20/
R 20/
Both 20/
L 20/
Not prescribed
Prescribed
To be worn all the time
To be worn for close work only
To be worn for distance only
Safety lenses
L 20/
Preferential seating recommended
Special materials that would be helpful
Other recommendations or suggestions
Date student should return for further examination
Signature
Date
Address