Vision and Hearing Cheat Sheet:
By law, all referral letters must be mailed to families using the US postal service.
1. Distance Visual Acuity test
Purpose- to test clearness of vision when looking in the distance; to detect myopia
(nearsightedness), amblyopia, and astigmatism.
When to do test: Kindergarten, 1st, 2nd, 3rd, 5th, 7th, 9th, special education students, new
students, and referrals.
Screening:
 Use a distance Sloan 10 or 20 foot chart and an occluder
 Mark 10 or 20 feet distance from chart with tape on floor for whichever chart you are
using.
 Make sure chart is at child’s eye level.
 Place heels on tape; keep both eyes open but occlude one eye at a time with occluder.
 Do not allow the child to squint, and/or lean the torso or head forward.
 If child wears glasses they should wear glasses during screening, this is referred to as
“corrected”; they should be tested with and without glasses to get a baseline for the child.
 When testing start with at least the 20/50 line and move down to 20/20 line. If the student
is unable to read 20/50 line move upward.
 Pick out three in line, if pass all three they pass that line
Note: Number of misses allowed in the line to pass:
1-3 optotypes = No misses
4-7 optotypes = One miss
8-11 optotypes = Two misses
Referral Criteria:
For students in first through 12th grade each eye must see at least the 20/30 line; if not the
student should be referred. The important exception is a two-line difference between the eyes;
for example, if the right eye was 20/20 and the left eye was 20/30, they would need to be
referred. Kindergarteners pass at 20/40 since vision is still developing.
2. Plus Lens Test
Purpose- to detect the refractive error, hyperopia (formerly termed “farsightedness”) in which
incoming images converge “behind” the retina and not on it resulting in a blurred image.
Screening:
 Place a +2.50 D lens over the eye being tested and the occluder over the other eye.
 Test on the distance Sloan chart’s 20/30 line
 If unable to read any symbols the child passes
 If able to read ANY on line, retest in two weeks
Referral Criteria:
Refer if child can read any of the 20/30 line while looking through the plus lens. Refer for one or
both eyes failing.
3. Convergence test
Purpose – to screen for convergence insufficiency. During convergence you contract your
eye muscles to pull your eyes together so that you can converge on a nearer point. This skill
is crucial for reading since most reading is done at a relatively close distance.
Screening:
 The child needs to be able to converge at 3 inches or closer
 Looking to see if eyes do not converge.
 If the child has reading glasses – do the test once with the glasses and once without
the glasses. If the child wears glasses for distance – do not have them wear glasses
during test.
Referral Criteria:
Refer if the student is unable to converge to at least 3 inches from the bridge of the nose
after re-screen.
4. Cover test
Purpose: To test eye alignment and detect potential misalignment; detects strabismus
Screening:
 Have child focus eyes on an object that you are holding at your midline.
 Hold the occluder upside down (with the handle up) in your dominant hand. Move it
back and forth rapidly over the bridge of the child’s nose occluding one eye and then
the other. The fairly rapid speed, about 1 second for each eye, is necessary to
prevent the child from targeting the focal object with both eyes simultaneously
 Observe the eye as the cover is being removed
 Repeat same procedure with child looking at something farther away (something
mounted on the wall over your shoulder is good b/c then you can watch their eyes
easily)
 If student wears glasses, test with glasses on.
Referral Criteria:
 Any consistent movement of the covered or uncovered eye while student has gaze
fixated on an object is a referral.
5. External Observation and History
Purpose: To detect any outwardly obvious eye problems or abnormalities.
Screening:
 ABC checklist
o ABC checklist should be distributed to the teachers prior to the screening.
o It could also be printed in the school newsletter for parents
 External observation – you are looking into the child’s eyes for any structural
abnormalities. Possible things you are looking for:
o One eye turns in or out at any time; eyes are crossed
o Pupils/eyes appear different sizes
o
o
o
o
o
o
Reddened eyes or lids
Eyes tear excessively
Drainage encrusted eyelids
Frequent sties or swollen lids
Drooping lids
Discharge from the eyes
Referral Criteria:
If a student has any of the listed symptoms on the ABC checklist, even if he or she passes all
other vision screening, he/she should be referred. Any of the above external observations
are reason for referral.
6. Stereo/Depth Perception
Purpose: To test for stereo/depth perception
Screening:
 Place book on table or desk in front of child. Child wears glasses.
 If child wears glasses, test with them on. Put the polarized glasses over them.
 Fly is really easy so make sure to do tests on left side of page (animals for younger kids,
circles for 2nd grade and up)
Referral Criteria:
Refer if the Fly is not seen 3-dimensionally in younger students. Refer students in second
grade or higher if unable to identify the correct response in at least five of the numbered
circles.
7. Color Vision Screening:
Purpose: To identify any problems with the child’s ability to recognize color.
Screening:
 Older child should read numbers. Younger children should trace design.
 Use cotton swab or something similar to have child trace design.
 No specific criteria on how many they can miss.
Referral Criteria:
Failure in this test is not a cause for referral to an eye care practitioner since no correction
is possible. Reevaluate 6-12 months later. Provide consultation to parents and teachers. See
Guidelines for School Vision Screening for further steps.
Hearing Cheat Sheet
Screening:
1. All students in grades kindergarten, 1st, 2nd, 3rd, 5th, 7th, and 9th
2. All transfer students entering without current screening records, within two months
of school enrollment
3. All students who have failed the previous year’s screening and who were not cleared
by an audiologist
4. All students receiving special education and/or related services (students who are
being assessed for special education services should have been screened within
the preceding twelve months)
5. All children enrolled in public-funded early childhood programs
6. All infant and preschool children upon referral through existing community Child
Find processes.
Test frequencies and screening levels:
500 Hz - 20dB for preschool through 5th grade; 25dB is acceptable if ambient noise levels are
high; 500 Hz is optional for 6-12th grades if negative history of hearing loss
1000 Hz - 20dB
2000 Hz - 20dB
4000 Hz - 20dB
6000 Hz - 25dB for 6-12th grades; (optional for all other grades)
Referral Criteria:
 Structural abnormalities of the outer ear, ear canal, or eardrum
 Ear canal drainage
 If fail 1 frequency on one ear or both
Special Considerations:
All students with any hearing loss, or at-risk for hearing loss, should have their hearing
monitored yearly.
This population includes children and youth:
 with tubes
 with a history of otitis media
 at risk due to family history of hearing loss
 with medical conditions which are known to cause hearing loss
 who are taking medications which may be ototoxic
 who are exposed to excessive noise levels
 with any degree of hearing loss
 with progressive hearing loss
 with other risk factors known to be associated with hearing problems.