vision screening progam – digital screening record – FY21
Michigan Department of Health and Human Services
Name: _______________________________________	Date of Birth: ____/____/20____	Age: ____
County: ______________________________________	Screening Date: ____/____/20____
Screening (check one)	Preschool	Kindergarten-Entry	Special Needs	UTS
Referral Outcomes (check all that apply)
Unit	Pass	Myopia	Hyperopia	Astigmatism	Gaze	Other
Blinq
Plusoptix
SPOT
Technician: ___________________________________	Date: ____/____/____
MDHHS-5904 (11-20)
vision screening progam – digital screening record – FY21
Michigan Department of Health and Human Services
Name: _______________________________________	Date of Birth: ____/____/20____	Age: ____
County: ______________________________________	Screening Date: ____/____/20____
Screening (check one)	Preschool	Kindergarten-Entry	Special Needs	UTS
Referral Outcomes (check all that apply)
Unit	Pass	Myopia	Hyperopia	Astigmatism	Gaze	Other
Blinq
Plusoptix
SPOT
Technician: ___________________________________	Date: ____/____/____
MDHHS-5904 (11-20)