Department of Education

Region VII, Central Visayas

DIVISION OF CEBU

CONSOLIDATED SCHOOL REPORT OF THE VISUAL ACUITY RESU

( ) Elementary ( ) Secondary
S.Y.: 2018 - 2019
SCHOOL: DISTRICT:
NUTRITION COORDINATOR / F.A.T.: ADMINISTRATOR:

HEADACHE / VISUAL ACUITY RESULTS

DIZZINESS WHEN SQUINT
GRADE / YEAR READING WITH EYEGLASSES WITHOUT EYEGLA
LEVEL NUMBER NUMBER RIGHT EYE LEFT EYE RIGHT EYE
YES NO YES NO READING M F READING M F READING M F
GRADE 1 / 1ST YR M F M F M F M F 20 / 200 20 / 200 20 / 200
ENROLMENT 20 / 60 20 / 60 20 / 60
M F 20 / 40 20 / 40 20 / 40
TOTAL = 20 / 30 20 / 30 20 / 30
TOTAL NO. WITH DEFECTS
TOTAL NUMBER W/ NORMAL VISION 20 / 20 20 / 20 20 / 20

GRADE 2 / 2ND YR M F M F M F M F 20 / 200 20 / 200 20 / 200

ENROLMENT 20 / 60 20 / 60 20 / 60
M F 20 / 40 20 / 40 20 / 40
TOTAL = 20 / 30 20 / 30 20 / 30
TOTAL NO. WITH DEFECTS
TOTAL NUMBER W/ NORMAL VISION 20 / 20 20 / 20 20 / 20

GRADE 3 / 3RD YR M F M F M F M F 20 / 200 20 / 200 20 / 200

ENROLMENT 20 / 60 20 / 60 20 / 60
M F 20 / 40 20 / 40 20 / 40
TOTAL = 20 / 30 20 / 30 20 / 30
TOTAL NO. WITH DEFECTS
TOTAL NUMBER W/ NORMAL VISION 20 / 20 20 / 20 20 / 20

GRADE 4 / 4TH YR M F M F M F M F 20 / 200 20 / 200 20 / 200

ENROLMENT 20 / 60 20 / 60 20 / 60
M F 20 / 40 20 / 40 20 / 40
TOTAL = 20 / 30 20 / 30 20 / 30
TOTAL NO. WITH DEFECTS
TOTAL NUMBER W/ NORMAL VISION 20 / 20 20 / 20 20 / 20

GRADE 5 / GR XI M F M F M F M F 20 / 200 20 / 200 20 / 200

ENROLMENT 20 / 60 20 / 60 20 / 60
M F 20 / 40 20 / 40 20 / 40
TOTAL = 20 / 30 20 / 30 20 / 30
TOTAL NO. WITH DEFECTS
TOTAL NUMBER W/ NORMAL VISION 20 / 20 20 / 20 20 / 20

GRADE 6 / GR XII M F M F M F M F 20 / 200 20 / 200 20 / 200

ENROLMENT 20 / 60 20 / 60 20 / 60
M F 20 / 40 20 / 40 20 / 40
TOTAL = 20 / 30 20 / 30 20 / 30
TOTAL NO. WITH DEFECTS
TOTAL NUMBER W/ NORMAL VISION 20 / 20 20 / 20 20 / 20
SUMMARY:
TOTAL NO. WITH DEFECTS: MALE: FEMALE: TOTAL:
TOTAL NO. WITH NORMAL VISION: MALE: FEMALE: TOTAL:
TOTAL NO. SCREENED: MALE: FEMALE: TOTAL:
TOTAL ENROLMENT: MALE: FEMALE: TOTAL:

PREPARED BY: NOTED:

SCHOOL NUTRITION COORDINATOR / F. A. T SCHOOL HEAD

TY RESULTS

TOTAL
OUT EYEGLASSES NUMBER
SCREENED
LEFT EYE
READING M F M F T
20 / 200
20 / 60
20 / 40
0
20 / 30

20 / 20

20 / 200
20 / 60
20 / 40
0
20 / 30

20 / 20

20 / 200
20 / 60
20 / 40
0
20 / 30

20 / 20

20 / 200
20 / 60
20 / 40
0
20 / 30
 0

20 / 20

20 / 200
20 / 60
20 / 40
0
20 / 30

20 / 20

20 / 200
20 / 60
20 / 40
0
20 / 30

20 / 20

CHOOL HEAD:
 Department of Education
Region VII, Central Visayas
DIVISION OF CEBU

VISION TEST ACUITY RESULTS

S.Y. 20___ - 20___

SCHOOL: DISTRICT: DATE EXAMINED:

GRADE / LEVEL: SECTION:

HEADACHE, READING RESULTS

NAUSEA, SQUINT

KS
NAME of PUPILS /
AGE SEX

AR
DIZZINESS WITH EYEGLASSES W/OUT EYEGLASSES
STUDENTS

EM
YES NO YES NO ( R) EYE ( L) EYE ( R) EYE ( L) EYE

R
PREPARED BY:

Class Adviser