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EYE REPORT AND RECOMMENDATIONS *OSIS # (Please print on hard surface) CHILD S LAST NAME: CHILD S FIRST NAME: SCHOOL # DATE OF BIRTH BOROUGH DISTRICT *Date of issue: *Reason for issue: *Issued by: GRADE/CLASS SEX: Male Female *Title: TO THE PARENT: Your child did not pass one or more parts of the vision screening. Please take your child to an eye doctor for an eye examination. SCREENING RESULTS: Date of screening: Team.

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