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Vision And Hearing Screening -Form Fill
Section One
Q1
Date*
Month
Q2
Date*
Day
Q3
Date*
Year
Q4
Student Name:*
Q5
Teacher Name:*
Q6
Grade:*
Please Select
Kindergarten
1st grade
2nd grade
3rd grade
4th grade
5th grade
Q7
Comments:
Q8
Date of Vision Test:
Month
Q9
Date of Vision Test:
Day
Q10
Date of Vision Test:
Year
Q11
Results of Vision Test:
Q12
Date of Hearing Test:
Month
Q13
Date of Hearing Test:
Day
Q14
Date of Hearing Test:
Year
Q15
Results of Hearing Test:
Q16
Comments:
Q17
Nurse's Signature
Q18
Date of Signature
Month
Q19
Date of Signature
Day
Q20
Date of Signature
Year
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