Prevent Blindness Ohio: Survey - Prevent Blindness Ohio Adult Vision Screening Recertification Exam

Prevent Blindness Ohio Adult Vision Screening Recertification Exam

Instructions

Please answer the following questions. You may submit your test online or print and return this test to Lauren Mackowiak at Prevent Blindness Ohio, 1500 W. Third Avenue, Columbus, Ohio 43212. Tests may also be faxed to Lauren’s attention at 614/481-9670. It is important that you take the time to read through the Adult Vision Screening Participant Guide manual before taking the test. There are several key components to an adult vision screening that you may want to reeducate yourself about to achieve a passing score.

1.

Please provide the following information before starting the test.

*

Name:

Title	First Required	Middle Required	Last Required	Suffix

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	StateRequired	ZIPRequired

Phone Number:

Occupation:

Remember me. What's this?

2.

Company/organization (if applicable)

(Maximum response 255 chars, approx. 5 rows of text)

3.

If you are a primary care provider, do you accept Medicaid patients?

*4.

Date of Vision Screening Training

Month

Day

Year

Recertification Exam

*5.

Vision screening tests are used to diagnose persons with eye diseases or disorders.

*6.

The subject whose acuity is 20/50 or worse in either eye is referred to an eye doctor.

*7.

Tests and procedures required in the Prevent Blindness adult vision screening are:
Registration/risk assessment, distance visual acuity, near visual acuity, visual fields for subjects age 40 and over or with a family history of glaucoma, exit interview
Registration, distance visual acuity, near visual acuity, tonometry, visual fields for subjects age 40 and over, exit interview
Risk assessment, distance acuity for those over 65, exit interview
Distance acuity, visual fields for those over 50, tonometry, professional interview
Registration, near acuity, visual fields for subjects age 45 and older, exit interview

*8.

The visual field test is used to screen for possible visual field loss that may be due to:
Macular Degeneration
Cataract
Glaucoma
Eye injury
Floaters

*9.

Identify the purpose(s) of vision screening: (select all that apply)

	Provide information and education about eye care
	Possible detection of eye disease in early or treatable stage
	Prescribing of appropriate treatment for eye disease
	Examines subjects for eye disorders and disease
	Identifies subjects at risk for eye disease

*10.

A subject should be told to see an eye care professional "now" based on:
Visual acuity of 20/50 or worse
Change in vision in the last 12 months
No dilated eye exam in the last two years
Previous eye injury or eye surgery
None of the above

*11.

Risk assessment factor(s) are: (select all that apply)

	Subject is over age 65
	Subject is black and over age 45
	Subject has not had a dilated eye exam in the last year
	Subject has noticed a change in vision in the last 12 months
	Subject has a family history of diabetes

*12.

In the question, "Do you have blood relatives with glaucoma?" blood relatives means
Parents, aunts, uncles, children
Mother, father, siblings, children, grandparents
Grandparents, parents, cousins, aunts, uncles
Parents, great grandparents, children
Parents, aunts, uncles, children
Mother, father, siblings, children, first-cousins

*13.

Visual field is defined as
The area or extent of physical space visible at a distance of 10 feet
The greatest distance at which the subject correctly identifies the 20 foot line
The area or extent at which one can discern fine detail in peripheral vision
The area of sharpest visual acuity; generally central vision
The area or extent of physical space visible to an eye in a given position

*14.

Appropriate follow-up practices may include: (select all that apply)

	Weekly phone calls to the referred subject until a doctor's appointment is scheduled
	Indefinite continuation of contact until confirmation of an exam is received
	Regular periodic contact until confirmation of an exam is received, or for about 6 months
	Providing the phone number of Prevent Blindness' office where someone is available to answer questions
	Phone calls or written correspondence, depending on available resources

*15.

Loss of central vision is a typical symptom of glaucoma.

*16.

A family history of diabetes is considered a factor in the risk assessment.

*17.

Previous eye surgery increases an individual's risk for developing glaucoma.

*18.

Discussion of screening test results is best addressed at the exit interview station.