Forms → Staff → ADAAA Accommodations → Binocular Disorder Questionnaire

Binocular Disorder Questionnaire

About this Form

Form number: 272-7A

Audience:  MCPS Staff, School Staff, Teachers

Last revised: March 2018

INSTRUCTIONS: Following receipt of a private medical report with a diagnosis of a binocular disorder such as Convergence Insufficiency, please complete the following questionaire. Send to the DHOH/Vision Program, English Manor site, fax to 240-740-1804, or via e-mail to: DHOHVision@mcpsmd.org

Adobe PDF Binocular Disorder Questionnaire78 KEnglish

Forms require Adobe Acrobat Reader 8 or higher. Get Acrobat