Prevent Blindness America: Survey - PBTX Adult Vision Screening Request Form

PBTX Adult Vision Screening Request Form

Please fill out the information below. If Prevent Blindness Texas is able to participate, we will send a fax or email a confirmation.

If you would like Prevent Blindness Texas to conduct a screening at your event, please be prepared to provide the following: 2 tables, 6-8 chairs, an electric outlet for 2 equipment items, a small trash bin, and a quiet indoor location (away from bright daylight).

*1.

Question - Required - Name of organization requesting the screening.

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

2.

Additional contact information

*

Name:

First Required	Last Required

*

Email: Required

*

Street 1: Required

Street 2:

*

City/State/ZIP:

City Required	State Required	ZIP Required

*

Phone Number: Required

Yes, I would like to receive e-mail from Prevent Blindness America

Yes, I would like to receive postal mail from Prevent Blindness America

Remember me. What's this?

3.

Question - Not Required - Name of event

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

4.

Question - Not Required - Name of sponsoring company

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

5.

Question - Not Required - Address of the event

*6.

Question - Required - Event date

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

*7.

Question - Required - Event start time

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

*8.

Question - Required - Event end time

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

*9.

Question - Required - Time allowed to begin set-up

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

*10.

Question - Required - Parking/unloading of equipment instructions

*11.

Question - Required - Indoor/outdoor

*12.

Question - Required - Event type

	vision screening
	health fair
	other

*13.

Question - Required - Population

	African American
	Asian
	Caucasian
	Hispanic
	Native American
	Seniors
	Other

*14.

Question - Required - Number of people expected to attend event

*15.

Question - Required - Age range

*16.

Question - Required - What language does the population being served speak?

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

*17.

Question - Required - will an interpreter be available?

*18.

Question - Required - Do we need to provide Spanish language materials?

*19.

Question - Required - What medical/vision coverage does the population have?

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