OCFS-1119 (Rev 10/2013)

 

NEW YORK STATE

OFFICE OF CHILDREN AND FAMILY SERVICES

Commission for the Blind

LOW VISION EVALUATION REPORT


THIS SECTION TO BE COMPLETED BY COUNSELOR OR PRIVATE AGENCY CASE MANAGER

ex: 03/22/1959

THIS SECTION TO BE COMPLETED BY LOW VISION SPECIALIST





NEAR

RECOMMENDED OPTICAL DEVICES

 

Narrative Report: (include information on tasks to be performed, client's acceptance of devices, special conditions required, such as lighting, posture, time restrictions, etc.)

ex: 03/22/2011

ex: 03/22/2011

ex: 03/22/2011


ADDITIONAL COMMENTS: