Prevent Blindness Ohio Adult Vision Screening Survey - 2007

1.	Question - Not Required - Since attending the adult vision screening training provided by Prevent Blindness Ohio, have you used your screening skills and equipment to perform vision screenings? Please select response Yes No
2.	Question - Not Required - If you answered Yes to question 1, have you experienced any difficulty in performing the vision screenings? Please explain.
3.	Question - Not Required - If you answered no to question 1, what are the reasons you have not performed a screening? Please explain, then go to question 12.
4.	Question - Not Required - If you answered Yes to question #1, have you implemented the vision screening steps consistent with the training, including a near and distance visual acuity, risk assessment, and visual fields test? Please select response Yes No
5.	Question - Not Required - If no, please explain.
6.	If you answered Yes to question #1, how do you handle adults who do not pass the vision screening? (Select one of the available choices or enter a different value.) Question - Not Required -If you answered Yes to question #1, how do you handle adults who do not pass the vision screening? Click this to indicate that you will select an existing value. Tab to next input." If you answered Yes to question #1, how do you handle adults who do not pass the vision screening? Please select response refer to an eye care professional attempt to re-screen other If you answered Yes to question #1, how do you handle adults who do not pass the vision screening? Click this to indicate that you will enter a new value. Tab to next input." If you answered Yes to question #1, how do you handle adults who do not pass the vision screening? Provide your answer here
7.	If you answered Yes to question #1, how do you handle adults who are unable to complete the vision screening? (Select one of the available choices or enter a different value.) Question - Not Required - If you answered Yes to question #1, how do you handle adults who are unable to complete the vision screening? Click this to indicate that you will select an existing value. Tab to next input." If you answered Yes to question #1, how do you handle adults who are unable to complete the vision screening? Please select response refer to an eye care professional attempt to re-screen other If you answered Yes to question #1, how do you handle adults who are unable to complete the vision screening? Click this to indicate that you will enter a new value. Tab to next input." If you answered Yes to question #1, how do you handle adults who are unable to complete the vision screening? Provide your answer here
8.	Question - Not Required - When do you perform a vision screening in your office? (Check all that apply) With all Well Adult Exams (standard practice procedure) When adult expresses a concern When behaviors/risk factors associated with vision problems are observed (ie. Difficulty reading print, family history of glaucoma, has diabetes, etc.)
9.	Question - Not Required - Please describe any other situation(s) when you perform a vision screening in your office.
10.	Question - Not Required - How many adults have you screened in the past 12 months?
11.	Question - Not Required - How many adults have you referred in the past 12 months?
12.	Question - Not Required - Have you used CPT Code 99173 to seek reimbursement for an adult vision assessment? Please select response Yes No
13.	Question - Not Required - If yes, what percentage of third party insurers will reimburse your practice for this code? (% estimate)
14.	Question - Not Required - If no, why haven't you used CPT Code 99173?
15.	Question - Not Required - Do you currently use risk assessment questionnaires to identify patients that need additional test performed or referral for additional care? Please select response Yes No
16.	Question - Not Required - If Yes, what are the conditions that you use risk assessment questions to identify (such as diabetes, vision, etc)?