iSee Clinic Request



Thank you for your interest in hosting the Ohio Optometric Foundation’s (OOF) In School Eye Exam (iSee) program. Completion of this form is necessary for the OOF to determine need and capacity to deliver the iSee program to your school.

School Information

School Name:
City:
County:
School District:
Primary Contact
First Name:
Last Name:
Position:
Phone:
Email:



School Information

School Enrollment #s:

% of students on IEP:

% of students disadvantaged:

Most recent school vision screening:	?

# of students screened:

# of students referred for eye exam:

# of students not receiving follow-up care:

Scheduling Timing

School start time:
School end time:

First choice dates:
Second choice dates:
Third choice dates:

- denotes required fields