Forms

Dr. Maino with student

How to schedule a KanLovKids Clinic
Low Vision Evaluation (LVE) or 
Pediatric Low Vision Collaboration Clinic (PLVCC)

  • Please contact Anne Nielsen by email anielsen@kssdb.org or phone 913-305-3041 to setup a clinic in your area, and to discuss which type of Low Vision Clinic would be more appropriate.
  • Anne will contact the doctor’s office to setup a date and time for the evaluations and then work with you to arrange the Clinic Schedule.
  • Forms for the clinics (Low Vision or Pediatric Low Vision Collaboration Clinic) can be downloaded from the KanLovKids website at http://kanlovkids.kssdb.org in a pdf format.

Forms needed for Low Vision Evaluation Clinic are:
  1. Consent Form;
  2. Contact Information Form (Use Child/Student’s Legal Name);
  3. Child-Student Eye Doctor's Information
  4. Impact of Vision Impairment for Children (IVI-C for 8 – 18 years of age);
  5. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, and Orientation and Mobility Report;
  6. Low Vision Evaluation Clinic Schedule - complete as a Word document and email to Anne Nielsen, anielsen@kssdb.org, or Erin Kelly, ekelly@kssdb.org, one month in advance of the clinic date;
  7. Low Vision Clinic Parent Letter; and
  8. BRING SAMPLES OF STUDENT’S WORKSHEETS, TEXTBOOKS, ETC.


Forms for Pediatric Low Vision Collaboration Clinic are:
  1. Consent Form;
  2. Contact Information Form (Use Child/Student’s Legal Name);
  3. Child-Student Eye Doctor's Information
  4. Child Family History Form;
  5. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, and Orientation and Mobility Report;
  6. Pediatric Low Vision Collaboration Clinic Schedule – complete as a Word document and email to Anne Nielsen, anielsen@kssdb.org, or Erin Kelly, ekelly@kssdb.org, one month in advance of the clinic date;
  7. Parent / Guardian Pediatric Low Vision Collaboration Clinic Letter; and
  8. BRING SUPPORTED SEATING EQUIPMENT AND TRAVEL OR WHEELCHAIR TRAYS ALONG WITH TOYS OR OBJECTS THE CHILD LIKES TO PLAY WITH.

  • Completed forms need to be scanned and emailed to Erin Kelly one month in advance of the clinic date.
Erin Kelly, KSSB, 1100 State Avenue, Kansas City, KS 66102
Email: ekelly@kssdb.org
913-305-3061
  • Erin Kelly will upload the completed documents in KSSB’s Google Drive so that the doctor will have on-line access to prepare for the evaluation.
  • After the evaluation, a report will be generated by the doctor and distributed to you to deliver to the family and school.
  • KSSB will send an invoice to your district after completion of the LVE or PLVCC for the children/students assessed.  The invoice will be sent to the designated person indicated by you on the Contact Information form.

Other Forms

Ċ
Bradley Hook,
Apr 20, 2015, 9:33 AM
ĉ
Ksb Admin,
Jun 12, 2015, 11:58 AM
Ċ
Ksb Admin,
Apr 5, 2016, 8:14 AM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:38 PM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:39 PM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:41 PM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:54 PM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:45 PM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:48 PM
Ċ
Sonya Fendorf,
Nov 9, 2011, 1:22 PM
Ċ
Sonya Fendorf,
Nov 9, 2011, 1:28 PM
Ċ
Sonya Fendorf,
Nov 7, 2011, 12:54 PM