Prevent Blindness Ohio: Survey - 2009 Vision Screener Survey

2009 Vision Screener Survey

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 (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!

1.

Please provide the following information:

*

Name:

First Required	Last Required

*

Email: Required

*

City/State/ZIP:

City Required	State Required	ZIP 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?

*2.

Question - Required - Your organization:

*3.

Please check which best applies to you:

(Select one of the available choices or enter a different value.)
Question - Required -

*4.

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)?

5.

Question - Not Required - If you answered "No" to the last question, please 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 equipment
	No reimbursement
	Not supported by management
	No time
	Other

6.

Question - Not Required - If you listed "other," please describe

7.

Question - Not 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

8.

Question - Not Required - If you listed "other," please describe

9.

Question - Not Required - When you've encountered difficulties screening preschool aged children (ages 3-6 years), what have you done (mark all that apply)?

	Rescreened
	Referred to eye care professional
	Stopped process
	Other

10.

Question - Not Required - If you listed "other," please describe

11.

Question - Not Required - Which of the following steps do you take when performing preschool age children (ages 3-6 years) vision screenings (mark all that apply)?

	Observation
	Visual acuity (Lea Chart)
	Stereopsis/RDE
	Other

12.

Question - Not Required - If you listed "other," please describe

*13.

Question - Required - How many preschool age children (ages 3-6 years) did you screen in the past 12 months

*14.

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

*15.

Question - Required - What percentage of these children were black/African American?

*16.

Question - Required - What percentage of these children were Hispanic/Latino?

*17.

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

*18.

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

*19.

Question - Required - What percentage of these children were Multiracial?

*20.

Question - Required - How many preschool age children (ages 3-6 years) did you refer to an eye doctor in the past 12 months (if zero, please write '0' in the space provided)?

*21.

Question - Required - Estimate the percent of referred children who received follow up care.

*22.

Question - Required - Do you provide feedback on the results of the vision screening to the child's medical home?

*23.

Do you or your office utilize the CPT Code 99173 to seek reimbursement for a pediatric vision assessment?

(Select one of the available choices or enter a different value.)
Question - Required -

24.

Question - Not Required - If you answered "No" (please describe why not)

25.

Question - Not Required - Please let us know about some of the children whose 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 program operating.

26.

Question - Not Required - Can we contact you with questions about your story?

27.

Question - Not Required - I hereby authorize Prevent Blindness Ohio to use the above information 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.

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