MINISTRY OF PRIMARY AND SECONDARY EDUCATION

LEARNERS’ VISION AND EYE HEALTH RECORD SHEET

First Name ------------------------------------------------------------------------------------

Sex------------------------------------

Surname ------------------------------------------------------------------------------------------

Birth Certificate Number ----------------------------------------------------------------------------------

Learner Welfare, Psychological Services and Special Needs Education Department

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VISION AND EYE HEALTH RECORD SHEET

Province---------------------------------------------------------------------------------------------

District-----------------------------------------------------------------------------------------------

Name of School------------------------------------------------------------------EMIS Number-----------

Name of Learner------------------------------------------------------------------------------------

Date of birth---------------------------------------------------------------------Age---------------------------

Sex ------------------------------------------------------------------------Grade ------------------------------

Birth Certificate Number ----------------------------------------------------------------------------------

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 The information below should be collected from parents or guardians through interview
and observation.

Item Indicator Nearly sometimes rarely never

always
1. Learner continues poking or rubbing eyes.
2. Learner holds reading materials at unusual position as if
trying to see well.

3. Learner holds reading materials too close or too far.

4. Learner has a discharge in eyes
5. Bumps into objects
6. Holds onto walls, objects, desks, chairs when moving
7. Learner frequently misses targets in games.
8. Learner has red or discoloured eyes.
9. Learner squints.
10. Learner has more sensitivity to light than others
11. Learner has difficulties identifying, detecting and
contrasting colours and shades.
Red
Blue
Yellow
Green
Black
12. When colouring learner colours outside defined borders.
13. Learner does not focus on visual stimuli clearly.
14. In reading and writing learner shows signs of visual
problems
Reading: Omissions
Substitution
Reversals
Missing initial, middle, final part of words
Writing: consistently follow lines
Writes outside the box

15. Learner relies on feeling objects instead of using eyes

(Please describe what you have observed to justify your
responses)
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Date of screening--------------------------------------------------------------------------------------------

Screened by----------------------------------------------------------------------------------------------------

EC number/National ID--------------------------------------------------Signature---------------------

Supervised by-------------------------------------------------------------------------------------------------

EC number/National ID---------------------------------------------------Signature----------------