Eye Screening Data

EYE SCREENING DATA PAGE

* Indicates required field

PERSON COMPLETING THIS FORM *

First

Last

Phone Number *

Type of Screening *

School Screening Health Fair Community Screening Other

CONTACT PERSONS Email *

LOCATION OF SCREENING *

Number Screened *

Number Referred (0 if none) *

Lions Club(s) Doing Screening *

DATE OF SCREENING *

Choose Your District *

District A District B District C

Other Comment *

Submit