Stem School Highland Ranch Hearing/Vision Screening Survey

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We are asking parents to take a minute to fill out this hearing and vision observation screening survey. This survey will help us to determine which students will need to receive hearing/vision screenings. The deadline to complete this survey is Friday, March 5.

Your Email Address *

Student's Last Name *

Student's First Name *

Student's Grade *

Has your child been tested for Hearing and Vision within the past year? *

Yes

Maybe

If your child was tested, what were the results? *

Passed

Failed Vision - Referred to an Opthalmologist/Optometrist

Failed Hearing - Referred to an Adiologist

None of the Above

Failed Both Vision and Hearing

Do you have any concerns about your child's vision? *

Yes

Do you have concerns about your child's hearing? *

Yes

Submit

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