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Department of Education

Region VI Western Visayas


DIVISION OF ANTIQUE
San Jose, Antique

VISION AND AUDITORY SCREENING

Name of School: _________________________________________________________ Date Assessed: ________________________ Teacher: ________________________________________________

Vision Screening Auditory Screening


Name Age Sex Remarks
Left Eye Right Eye Left Ear Right Ear

Prepared by: Conforme:

JOFRED M. MARTINEZ, RN, MAN _______________________________________________


School Nurse School Head