ILLINOIS DEPARTMENT OF PUBLIC HEALTH VISION CONSERVATION ANNUAL REPORT - Instructions for Completing Form (IDPH/V-3)

Oct 10, 2026

Instructions for completing the Illinois Department of Public Health Vision Conservation Annual Report form (IDPH/V-3). The form specifies how to enter screening counts by preschool and school age, including totals for screened, rescreened, referred, and glasses referrals, then how to record follow-up outcomes for completed versus not completed medical referrals. It also details diagnosis categorization such as myopia, hyperopia, astigmatism, muscle balance, amblyopia, pathology, combinations, and normal results, plus reporting fields for special education referral criteria, color screening, and agency submission information. Reports are due by June 30.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages3

Reading Time8 min

AccessFree to download

Screening

Follow-up Results

Diagnosis

Program and Submission

ILLINOIS DEPARTMENT OF PUBLIC HEALTH VISION CONSERVATION ANNUAL REPORT INSTRUCTIONS FOR COMPLETING FORM (IDPH/ V-3) SCREENING Enter all screening data by preschool, in line a, and by school age, in lines b-o. All full-time special education class children must be entered on line o. Column 1. NUMBER SCREENED. Enter the total number of children instrument screened. (Do not enter children wearing glasses in this column.) 2. NUMBER RESCREENED. Enter the total number of children rescreened. 3. NUMBER REFERRED. Enter the total number of children who met referral criteria following rescreening and/or were referred because of observable symptoms. 4. NUMBER WITH GLASSES. Enter the total number of children in the groups you screened who were wearing glasses. 5. GLASSES REFERRAL. Enter the number of children wearing glasses who were referred. Sum data entered in each column, 1 through 5, and enter these sums on line p. FOLLOW-UP RESULTS Enter all follow-up results by school-age, in column 6, and preschool, in column 7. Number of Completed Medical Referrals (q) . Enter total number of children for whom a vision examination report has been returned or information obtained verifying examination and diagnosis. Do not include glasses referrals. Number of Referrals Not Completed (r) . Enter the total number of children for whom no report has been received or information obtained verifying an examination and diagnosis. Sum lines q, r and s, and columns 6, 7 and 8. The sums of column 8 and line s must be equal. The number entered in cell 8-s must equal the total number of children referred, cell 3-p. DIAGNOSIS Enter all diagnostic data by school age, in column 6, and preschool, in column 7. Total Number of Children Found To Have. Enter the total number of children with a diagnosis on the following lines: A. REFRACTIVE ERRORS 1. Myopia (t) 2. Hyperopia (u) 3. Astigmatism (v) 4. Other (w) B. MUSCLE BALANCE (x) C. AMBLYOPIA (y) D. PATHOLOGY (z) E. COMBINATIONS OF FINDINGS (aa) F. NORMAL (bb) Sum lines t through cc and columns 6, 7 and 8. The sums of 8-q and 8-cc must be equal. The number entered in cell 8-cc must equal the number of completed referrals, cell 8-q. NUMBER REFERRED TO SPECIAL EDUCATION (dd) . Enter the total number of children who met educational referral criteria. COLOR (ee) . Enter the total number of children screened for color and the total number who failed the screening. PROGRAM Print or type agency name, i.e. school district name and number, health department name or other agency name. Print or type agency address: number and street, city, ZIP code and county. Enter the name and telephone number of the individual submitting the report. Enter the date the report is submitted. Submit one cumulative annual report from each school district, health department or other agency responsible for vision screening. Submit this report to the Department’s Vision and Hearing Program by June 30 of each year. PLEASE TYPE OR PRINT LEGIBLY. CHECK ALL COMPUTATIONS. THIS FORM IS USED TO COMPILE STATEWIDE STATISTICS. THANK YOU FOR YOUR COOPERATION. ILLINOIS DEPARTMENT OF PUBLIC HEALTH DIVISION OF HEALTH ASSESSMENT AND SCREENING VISION CONSERVATION ANNUAL REPORT JULY 1, TO JUNE 30, | | 1 Number Screened | 2 Number Rescreened | 3 Number Referred | 4 Number of Children with Glasses | 5 Glasses Referral | FOLLOW-UP RESULTS | | 6 School
-age | | | 7 Preschool | |

8 Total | | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | | Preschool a | | | | | | Number of completed referrals ........ .......q | | | | | | | | | K b | | | | | | Number of referrals not completed ……..r | | | | | | | | | 1 c | | | | | | Total s | | | | | | | | | 2 d | | | | | | DIAGNOSIS | | | | | | | | | 3 e | | | | | | Total number of children found to have | | | | | | | | | 4 f | | | |

FAQs

What screening totals must be entered on the form?

Enter the total number of children screened, rescreened, and referred. Also record the number with glasses and the number of glasses referrals. Sum columns 1 through 5 and enter the totals on line p.

How should follow-up results be reported?

Report follow-up outcomes for preschool and school-age groups. Record the number of completed medical referrals (q) and the number of referrals not completed (r), then sum lines q and r to match the required totals.

Which diagnosis categories are included in the report?

The diagnosis section includes refractive errors (myopia, hyperopia, astigmatism, other), muscle balance, amblyopia, pathology, combinations of findings, and normal. Totals must be summed correctly across the listed categories and by age group.

Oct 10, 2026

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