VISION VAN / ADULT SCREENING COVER SHEET

Adult (7+ Years Old) Vision Screening Cover Sheet

First name of screener

Last name of screener

Screener / Photographer Email

Phone

Dat of Vision Screening

Lions Club

Lions Club Mailing Address

City

State

Postal / Zip code

Screening Site Name

Screening Site Contact Person

Screening Site Phone Number

Screening Site County

Screening Site Address

City

State

Postal / Zip code

Total # of People Screened (Ages 7 years old and up)

If using a SPOT camera, how many people passed the screening or were currently under treatment (have glasses or contacts already).

If using a SPOT camera, how many people failed or were a "referral" and NOT currently under treatment.

THANK YOU for providing these important screenings to individuals in your community and THANK YOU for submitting the Cover Sheet information to the Kentucky Lions Eye Foundation!

Adult (7+ Years Old) Vision Screening Cover Sheet

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