The Lions Club of West Virginia conducted a vision screening for multiple age groups at an unspecified event location. They screened individuals ages 6 months to 18 years old using Pediavision or PlusOptix equipment and those 19 years and older using tonometry or visual acuity tests. The report provides the number screened and referred in each age group along with volunteer hours. Results are to be mailed or emailed to the Lions contact for reporting.

1. LIONS MULTIPLE DISTRICT 29
WEST VIRGINIA
VISION SCREENING
REPORT
CLUB: _______________________ DATE OF SCREENING:_____________
LOCATION OF SCREENING: _______________________________________________
EVENT: _______________________________________________________________
EQUIPMENT USED: CIRCLE ONE OR MORE OF THE FOLLOWING
KidSight Equipment: A. Pediavision “SPOT” B. PlusOptix
Adult Equipment: C. Tonometer “Puff Machine” D. Titimus Visual Acuity
RESULTS
Age
Group
Numbered
Screened
Numbered
Referred
Volunteer
Hours
6 Mo. To 6 yrs.
7 yrs. to 18 yrs.
19 yrs. Plus
Print Name____________________________Signature______________________________
Email or Telephone___________________________________________________________
Mail or email to: Kim Ebert
PO Box 9193
Morgantown, WV 26506
ebertk@wvumedicine.org
or Fax to 304-598-6928