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Low Vision Collaborative Clinic Forms


A Low Vision Collaboration Clinic (LVCC) is generally for children/students that can interpret eye charts (numbers, letters or pictures) and communicate what they are seeing to the doctor.

Information needed for Low Vision Collaboration Clinic are: When emailing documents, please put clinic date in the subject box.
  1. Consent Letter
  2. Contact Information Form (Use Child/Student’s Legal Name)
  3. Patient's Eye Doctor Information
  4. Provide the most recent Eye Report, Functional Vision/ Learning Media Assessment, Clinic Low Vision Evaluation, and Orientation and Mobility Report
  5. Media Consent Form 
  6. Low Vision Clinic Parent Letter (please fill this out BEFORE sending it home to parents --parents keep this)  
  7. Fill this out  only if KSSB Field Services Specialists requests it for the doctor     Impact of Vision Impairment for Children (IVI-C for 12 to 18 years of age)    This form should be completed online, as it will be automatically scored. 

Please email documents (1-5) to Erin Kelly  ekelly@kssdb.org   913-305-3061      
ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  (be sure to indicate if ASL or Spanish interpreter is needed)
BRING SAMPLES OF STUDENT’S WORKSHEETS, TEXTBOOKS, ETC.

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