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The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time. The parent of any child who is unable to obtain an examination must submit a waiver form to the school.  \nStudent Name    \n(Last) (First) (Middle Initial)  \nBirth Date   Gender   Grade    \n(Month/Day/Year)  \nParent or Guardian    \n(Last) (First)  \nPhone    \n(Area Code)  \nAddress  (Number) (Street) (City) (ZIP Code)  \nCounty    \nTo Be Completed By Examining Doctor  \nCase History  \nDate of exam    \nOcular history: q Normal or Positive for    \nMedical history: q Normal or Positive for    \nDrug allergies: q NKDA or Allergic to    \nOther information    \nExamination  \n\n|  | Distance |  |  | Near |\n| --- | --- | --- | --- | --- |\n|  | Right | Left | Both | Both |\n| Uncorrected visual acuity | 20/ | 20/ | 20/ | 20/ |\n| Best corrected visual acuity | 20/ | 20/ | 20/ | 20/ |\n\nWas refraction performed with dilation? q Yes q No  \nExternal exam (lids, lashes, cornea, etc. ) Internal exam (vitreous, lens, fundus, etc. ) Pupillary reflex (pupils)  \nBinocular function (stereopsis) Accommodation and vergence Color vision  \nGlaucoma evaluation Oculomotor assessment  \nOther     \nNormal q  \nq  \nq  \nq  \nq  \nq  \nq  \nq  \nq  \nAbnormal q  \nq  \nq  \nq  \nq  \nq  \nq  \nq  \nq  \nNotAble to Assess qqqqqqqqq  \nComments  \nNOTE: \"Not Able to Assess\" refers to the inability of the child to complete the test, not the inability of the doctor to provide the test.  \nDiagnosis  \nq Normal q Myopia q Hyperopia q Astigmatism q Strabismus q Amblyopia  \nOther    \nPage 1 Continued on back  \n\n|  |\n| --- |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n\nState of Illinois  \nIllinois Department of Public Health  \nState of Illinois Eye Examination Report  \nRecommendations  \n1. Corrective lenses: q No q Yes, glasses or contacts should be worn for:  \nq Constant wear q Near vision q Far vision  \nq May be removed for physical education  \n2. Preferential seating recommended: q No q Yes  \nComments    \n______________________________________________________________________________________________  \n3. Recommend re-examination: q 3 months q 6 months q 12 months  \nq Other    \n4.    \n5.    \nPrint name   License Number    \nOptometrist or physician (such as an ophthalmologist) who provided the eye examination q MD q OD q DO  \nAddress    \nPhone    \nSignature    \nConsent of Parent or Guardian  \nI agree to release the above information on my child or ward to appropriate school or health authorities.  \n(Parent or Guardian’s Signature)  \n(Date)  \nDate    \n(Source: Amended at 32 Ill. Reg   , effective   )  \nPage 2  \nPrinted by Authority of the State of Illinois IOCI 15-391","cbCaimr0l8Mt9ud9","https://ap.wps.com/l/cbCaimr0l8Mt9ud9","pdf",184698,"English","# Student and Parent/Guardian Information\n## Eye Examination Documentation\n# Diagnosis and Recommendations\n## Consent and Signatures","[{\"question\":\"When must the eye examination proof be submitted to the school in Illinois?\",\"answer\":\"Illinois law requires submission no later than October 15 of the year the child is first enrolled, or as required by the school for other children.\"},{\"question\":\"What are the timing requirements for completing the eye examination before school begins?\",\"answer\":\"The examination must be completed within one year prior to the first day of the school year the child enters the Illinois school system for the first time.\"},{\"question\":\"What should a parent or guardian do if they cannot obtain the required eye examination?\",\"answer\":\"The parent or guardian must submit a waiver form to the school.\"}]","State of Illinois Eye Examination Report | PDF",1791603152]