Below you will find and be able to download all forms mentioned within the full protocol document, organized by station. Please use these as a guide for your own vision outreach program.
Geography specific versions
Additional program types
See to Learn (School setting)
Clear Vision Workplaces (Factory setting)
Pre-Outreach Program
Permission letter to local authorities
A draft letter to local authorities seeking permission to conduct the vision outreach. This letter is useful in the case of national lockdowns and/or restrictions and provides an overview of COVID-19 prevention practices, employee and customer safety and program activities.
Additional tips on social distancing
Includes additional details for social distancing and crowd control.
Handwashing Station
How to care for the handwashing station
A step-by-step guide to setting up and maintaining a hand washing station.
Informational graphics and leaflets for use at the handwashing station
Graphic guidelines to accompany handwashing stations. Each PDF includes a simplified 4-step guide, an 8-step guide, and ‘do not drink’ stickers to attach to the water drum.
Symptomatic Screening and Registration Station
Health Risk Assessment Form
The risk assessment form to be filled by the customer.
Symptomatic Screening Form (Excel)
The symptomatic screening form to be maintained by the registrar at the station.
Pre-Screening Station
Disinfection Guide
A guide that details the disinfectant types, tools and procedures at all stations of the vision outreach.
Refraction Station
Prescription Card
A sample VisionSpring prescription card that is given to the customer, to model for your own vision outreach setting.
A sample VisionSpring customer examination sheet, filled up with details by the optometrist.
Customer Examination Sheet
Glasses Selection, Payment and Counseling
Counseling Script
A guide for counselors to ensure an accurate and empathetic approach to educating customers on how to take care of and wear their new glasses.
Staff Safety
Additional tips on daily health reporting
Includes additional details on daily health reporting and symptom screening for team members.
Measurement and Feedback
Supportive Supervision Checklist
A checklist to promote mentorship, joint problem-solving and communication between supervisors and the supervised during vision outreach programs.
Customer Feedback Survey
A short survey to be given to customers after they complete the outreach process, used as a tool to continually improve upon each outreach program.
Camp Observer Checklist
A checklist with observation points to make sure the outreach is set up and operating with COVID-safety.