Form

IC 20-34-3-13 allows for schools to request a waiver for the MCT portion of the vision screening exam for students in grades K or 1 before November 1 of each school year. A waiver request must be made on an annual basis. To request a waiver, please complete and submit the following form.

1a. Corporation Name: *

1b. Corporation Number: *

2a. School Name: *

2b. School Number: *

3. Contact Information of Person Completing Report

Full Name *

First Name Last Name

Job Title *

E-mail *

Phone Number *

- Area Code Phone Number

4. Requesting Waiver for (choose one) *

Kindergarten Grade 1

5. Total Number of Students Requesting a Waiver. *

6. Primary Reason for Requesting a Waiver (choose one) *

Unable to obtain the volunteer services of a properly licensed eye professional to conduct the MCT vision screening Lack of a sufficient number of properly licensed eye professionals in your area to perform the MCT vision screening Financial cost of providing transportation of students to a centralized vision screening site Loss of instruction time due to transportation of students to a centralized vision screening site

7. I understand that requesting a waiver for the MCT portion of the vision screening exam does not relieve the school of the responsibility for completing the visual acuity screening for students in grades K or 1. Our school plan for completing the visual acuity screening for student in grades K or 1 includes: (chose one) *

the school nurse will complete the vision acuity screening for students in grades K or 1 another agency (such as the health department or Lion’s Club) will complete the vision acuity screening for students in grades K or 1 trained volunteers will complete the vision acuity screening for students in grades K or 1