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Get Allen ISD Certificate of Record for Vision Screen and/or Eye Examination and Hearing Screening

__________ Vision: Right: 20/____ Left: 20/_____ ___With correction ___PASS / ___FAIL ___Without correction ___Suresight / ___Snellen / ___Titmus Hearing: 500Hz 1000Hz 2000Hz 4000Hz Right: Left: 25db HL 40 db HL ___Pass / ___Fail Rescreen recommended: ___Yes / ___No Physician/Screener Name:_________________________ Physician/Screener Signature or stamp:___________________________________ Date: __________________ .

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