Prevent Blindness Ohio: Survey - Preschool Vision Screener Questionnaire

Preschool Vision Screener Questionnaire

PBO_SaveOurSight

The preschool vision screening training program you participated in is funded by the Ohio Department of Health, Bureau of Child and Family Services, Save Our Sight Vision program (http://www.saveoursight.org/). The funds have helped improve the vision of thousands of children in Ohio through vision screening training programs, education programs, and protective eyewear programs.

Please take the time to provide the following information and thanks for your help!

If you return your survey to PBO by February 23rd, we will send you a $10 Staples® gift card! If we receive your completed survey after February 23rd, but prior to March 31st, we will send you a $5 Staples® gift card.

Please provide your contact information.

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Name:

First Required	Middle Required	Last Required

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Email: Required

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City/State/ZIP:

City Required	State Required	ZIP Required

Remember me. What's this?

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Question - Required - Your Organization:

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

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Question - Required - Please check which best applies to you: Health care professional (physician, nurse, medical student, medical assistant, school nurse)
Child care/Preschool professional (administrator, teacher, staff, volunteer)

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Question - Required - In the last 12 months, did you use your screening skills and equipment to perform vision screenings with preschool children (ages 3-6 years)?

Question - Not Required - If you answered "no" to the previous question, mark all the reasons you did not conduct any screenings and return this questionnaire in the envelope provided. Thanks for your help!

	Another person does screenings
	Change in job/position
	Change population(s) served
	No time
	No equipment
	No reimbursement
	Not supported by management
	Other (please describe)

Question - Not Required - If you answered "Other", please describe:

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Question - Required - When do you perform vision screenings (mark all that apply)?

	Preschool screening
	Kindergarten screening
	Beginning of school year
	Well Child visit
	Parent/guardian request
	Vision problem behaviors observed
	Other

Question - Not Required - If you answered "other," please describe:

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Question - Required - What difficulties have you encountered when screening preschool children (mark all that apply)?

	None
	Attention span
	Unable to follow directions
	Fear/scared
	Don't know shapes
	Language barriers
	Learning/behavior issues
	Too young to understand
	Other

Question - Not Required - If you answered "other," please describe:

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Question - Required - Are the steps you take to perform vision screenings consistent with the methods provided during training (i.e., observation, distance acuity, stereopsis)?

Question - Not Required - If you answered "no," please explain:

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Question - Required - On average, how many preschool age children do you screen per month? If zero, please write '0' in the space provided

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Question - Required - What percentage of these children were white:

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Question - Required - What percentage of these children were Hispanic or Latino:

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Question - Required - What percentage of these children were American Indian/ Alaska Native:

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Question - Required - What percentage of these children were Black/African American:

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Question - Required - What percentage of these children were Asian/Pacific Islander:

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Question - Required - On average, how many preschool age children do you refer to an eye doctor per month? If zero, please write '0' in the space provided.

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Question - Required - Do you or your office utilize the CPT Code 99173 to seek reimbursement for a pediatric vision assessment? yes
no
don't know

Question - Not Required - If you answered "no," please explain.

Question - Not Required - Please let us know about some of the children who vision was saved as a result of a vision screening that you or a co-worker conducted. Sharing these stories of success helps keep our programs operating.

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Question - Required - Can we contact you with questions about your story?

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Question - Required - I hereby authorize Prevent Blindness Ohio to use the above information and/or photographs in materials including, but not limited to, press releases, marketing materials, brochures, reports, media broadcasts for up to 10 years from the date of this release.

Question - Not Required - Other comments you may have: