Forms and Material for Clinical Directors
For instructions on how to conduct a screening, download the “Special Olympics — Lions Clubs International Opening Eyes Guidelines for a Standardized Vision Screening” manual (67 pages, created 1999, revised 2002, 2006, Adobe PDF, 2M). This manual was authored by:
Sandra S. Block O.D., M. Ed.
Opening Eyes Director of Research and Education
Professor, Illinois College of Optometry
+1 (312) 949-7276
+1 (312) 949-7369 (Fax)
sblock@ico.edu
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A Special Olympics St. Kitts & Nevis athlete models her new pair of eyeglasses after visiting an Opening Eyes screening event. |
Clinical Directors participating in Special Olympics — Lions Clubs International Opening Eyes who wish to receive information on the Opening Eyes official protocols should contact Dr. Block.
The following forms are designed for the use of Clinical Directors when administering their individual programs:
- Hold Harmless Agreement (Adobe PDF, 124K): All health care providers volunteering to conduct health screenings at Special Olympics Healthy Athletes events must have malpractice insurance that covers the Healthy Athletes related activites. This form's mutual hold harmless language is a method by which each party is protected.
- HAS Opening Eyes Screening form (Adobe PDF, 121K, updated 21 September 2006)
More information on HAS — Healthy Athletes Software system
- Manual for Healthy Athletes Software (HAS) Data Input (Adobe PDF, 121K)
- United States-based Program Needs form (rev. July 2006):
Microsoft Word document, 67K, or Adobe PDF, 103K
- Non-U.S.-based Program Needs form (rev. July 2006):
Microsoft Word document, 69K, or Adobe PDF , 126K (rev. July 2006)
- 2007 Event Data Summary form (Adobe PDF, 15K or Microsoft Word document, 37K)
- “Congratulations...glasses” form (Adobe PDF, 101K) or Microsoft Word document, 79K. [Note the space for customizing these with the Clinical Director's contact information using Microsoft Word.]
- “Screening Report Card” form, revised July 2006. Note the space for customizing these with the Clinical Director's contact information using Microsoft Word, after customization, print these pages on either side of an 8½" x 11" sheet of paper:
- Essilor Lenses Replacement Order form (Adobe PDF, 66K)
- Special Olympics — Lions Clubs International Opening Eyes Grant Application form (Adobe PDF, 10K)
The following forms, designed for the use of Clinical Directors when administering their individual programs, are in Spanish. Los formularios siguientes, diseñó para el uso de los Directores Clínicos al administrar sus programas individuales, están en Español:
For general questions about the Special Olympics — Lions Clubs International Opening Eyes programs, contact David Evangelista, Director, Health Programs, at +1 (202) 824-0314 or devangelista@specialolympics.org .
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