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PRESCHOOL FUNCTIONAL VISION/HEARING SCREENING Case Study Committee Referral Child s Name Referring Person Date of Birth This screening is for children ages 2 to 5 years. It does not evaluate vision or hearing acuity but it does address whether functional vision an/or hearing seems adequate to continue with the assessment process. VISION check all that apply Does the child. Have eyes that look forward not inward or outward Make eye contact with the objects Follow moving objects with eyes Look at objects without covering one eye or squinting Hold objects at a normal distance from face Move about without frequently bumping into objects Move easily from one floor surface to another Functional vision seems normal* A vision problem is suspected* Further evaluation is indicated* HEARING check all that apply Breathe through the nose with mouth closed Speak in a normal tone of voice Have a normal voice quality Speak clearly without misarticulations Look at the speaker s face rather than the speaker s lips Turn when name is spoken while child is not looking Functional hearing seems normal* A hearing problem is suspected* Further evaluation is indicated* Signature of Evaluator Title DoDEA Form 2500. It does not evaluate vision or hearing acuity but it does address whether functional vision an/or hearing seems adequate to continue with the assessment process. VISION check all that apply Does the child. Have eyes that look forward not inward or outward Make eye contact with the objects Follow moving objects with eyes Look at objects without covering one eye or squinting Hold objects at a normal distance from face Move about without frequently bumping into objects Move easily from one floor surface to another Functional vision seems normal* A vision problem is suspected* Further evaluation is indicated* HEARING check all that apply Breathe through the nose with mouth closed Speak in a normal tone of voice Have a normal voice quality Speak clearly without misarticulations Look at the speaker s face rather than the speaker s lips Turn when name is spoken while child is not looking Functional hearing seems normal* A hearing problem is suspected* Further evaluation is indicated* Signature of Evaluator Title DoDEA Form 2500.

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Keywords relevant to Functional Vision And Hearing Form

  • squinting
  • acuity
  • referral
  • Inward
  • preschool
  • Outward
  • evaluate
  • bumping
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