DAR File No. 43757

Health, Disease Control and Prevention, Health Promotion

Rule R384-201

School-Based Vision Screening for Students in Public Schools

Notice of Proposed Rule

(Amendment)

DAR File No.: 43757
Filed: 05/31/2019 03:32:45 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

Section 53G-9-404 was revised in the 2019 General Session with S.B. 143. Changes in legislation require this rule be updated.

Summary of the rule or change:

In the 2019 General Session, the statute on vision screening was revised. The Utah Department of Health (Department) will now oversee the school vision screening program. The school vision screening program is now required in all Utah public schools. These revisions to statute required changes to this rule. Because the revisions are extensive, it is necessary to repeal the old rule and reenact new language. Changes include moving the oversight of the vision screening program from the Division of Services to the Blind and Visually Impaired to the Department, requiring vision screening be done in specific grades, vision screening being comprised of tier 1 and tier 2 screening, the creation of training modules by the Department for vision screening, eliminating the state database for students who fail the vision screening, the creation of a symptoms questionnaire, and adding annual reporting requirements for local education agencies.

Statutory or constitutional authorization for this rule:

• Subsection 53G-9-404(6)

Anticipated cost or savings to:

the state budget:

The Department (EPICC Program) will monitor the vision screening requirement in Utah public schools. It is estimated that this rule will cost the EPICC program $32,000 annually, starting with FY 2020, to monitor. The EPICC program is expected to experience an ongoing direct fiscal cost of $32,000.

local governments:

Across the state of Utah 1,253 public schools (elementary and secondary schools NAICS 611110) will be required to provide vision screening to students. It is estimated that the cost to each school will be a one-time cost for equipment of $102, and an ongoing cost of $905 for school nurse salary and benefits. Local governments are expected to experience direct fiscal costs of $1,261,771 (one-time FY 2020), and $1,133,965 ongoing.

small businesses:

There are six types of healthcare providers who are currently allowed by statute to provide the vision screening required to enter Utah schools: optometrist (NAICS 621320), MD physician (NAICS 621111), DO physician (NAICS 621111), advance practice registered nurse (NAICS 621399), physician assistant (NAICS 621399), and vision therapist (NAICS 621399). Only two of these six types of providers are classified as eye care professionals (optometrist and ophthalmologist) who may provide a comprehensive eye exam for referrals when a student is not able to pass the vision screening. It is not possible to determine the number of referrals to an eye care professional. It is also not possible to determine the number of optometry and ophthalmology offices, and to further determine if those offices are small businesses or non-small businesses. The precise fiscal benefit to small healthcare provider business cannot be estimated due to the unavailability of data and high cost of conducting research to determine the estimates.

persons other than small businesses, businesses, or local governmental entities:

There are 658,952 students in Utah public schools that could experience an inestimable indirect non-fiscal benefit by receiving vision screening at no cost to their family. These screenings can detect many vision difficulties that may have gone undetected and untreated. It is difficult to estimate the monetary value of good vision health. An exact estimate of the non-fiscal benefit to these students is not possible because the data necessary to determine the benefit is not available.

Compliance costs for affected persons:

The cost for FY 2020 is $1,293,771. The cost for FY 2021 and ongoing will be $1,165,965.

Comments by the department head on the fiscal impact the rule may have on businesses:

Businesses may see a fiscal benefit if the school uses an outside healthcare provider who is qualified to provide vision screening.

Joseph K. Miner, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Office of Administrative Rules, or at:

Health
Disease Control and Prevention, Health Promotion
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

Direct questions regarding this rule to:

• BettySue Hinkson at the above address, by phone at 801-538-6814, by FAX at , or by Internet E-mail at [email protected]

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/15/2019

This rule may become effective on:

07/22/2019

Authorized by:

Joseph Miner, Executive Director

Appendix 1: Regulatory Impact Summary Table*

Fiscal Costs	FY 2020	FY 2021	FY 2022
State Government	$32,000	$32,000	$32,000
Local Government	$1,261,771	$1,133,965	$1,133,965
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Person	$0	$0	$0
Total Fiscal Costs:	$1,293,771	$1,165,965	$1,165,965
Fiscal Benefits
State Government	$0	$0	$0
Local Government	$0	$0	$0
Small Businesses	$0	$0	$0
Non-Small Businesses	$0	$0	$0
Other Persons	$0	$0	$0
Total Fiscal Benefits:	$0	$0	$0
Net Fiscal Benefits:	-$1,293,771	-$1,165,965	-$1,165,965

 

*This table only includes fiscal impacts that could be measured. If there are inestimable fiscal impacts, they will not be included in this table. Inestimable impacts for State Government, Local Government, Small Businesses and Other Persons are described in the narrative. Inestimable impacts for Non-Small Businesses are described in Appendix 2.

 

Appendix 2: Regulatory Impact to Non-Small Businesses

The regulatory and fiscal impact to non-small businesses is inestimable. It is unknown how many students may require referral to an eye care professional (optometrist or ophthalmologist) for a more comprehensive eye exam.

 

Additionally, a doctor of ophthalmology is included in the physician category under both NAICS and the Utah Division of Occupational and Professional Licensing. It is unknown how many licensed physicians specialize in ophthalmology. According to Department of Workforce Services Firm Find Data, no optometrists are listed as a non-small business.

 

 

R384. Health, Disease Control and Prevention, Health Promotion.

R384-201. School-Based Vision Screening for Students in Public Schools.

[R384-201-1. Authority.

(1) This rule is authorized by section 53A-11-203.

(2) The Department of Health is authorized under the rule to set standards and procedures for vision screening required by this chapter, which shall include a process for notifying the parent or guardian of a child who fails a vision screening or is identified as needing follow-up care; and provide the Division with copies of rules, standards, instructions; and recommendation for test charts necessary for conducting vision screening.

 

R384-201-2. Definitions.

(1) Division -- Division of Services for the Blind and Visually Impaired, State Office of Education.

(2) Eye care professional -- Ophthalmologist or optometrist

(3) LEA -- Local education agency

(4) Photoscreening -- Automated screening technique that facilitates vision screening in children, especially those that are difficult to screen (infants, toddlers, and children with developmental delays). It screens for a range of eye problems including most refractive errors, alignment errors, opacities (such as cataracts), and other visible eye abnormalities.

(5) Screening certificate -- Written documentation of vision screening or comprehensive eye examination by a licensed physician, or eye care professional that have been given within one year of entering a public school are acceptable.

(6) Sure Sight -- A vision screening auto-refractor that identifies nearsightedness, farsightedness, astigmatism and the difference between eyes.

(7) Significant visual impairment -- A visual impairment severe enough to interfere with learning. The term is the designation required for a child to receive services from district vision or Utah Schools for the Deaf and Blind (USDB).

(8) Screener -- Pediatricians, family practitioners, nurses, or trained medical staff can perform vision screening at regular well child office visits. In addition, school volunteers and groups are trained to support vision screening programs for children. A licensed health professional providing vision care to private patients may participate as a screener in a school vision screening program for a child nine years of age or older.

(9) USDB -- Utah Schools for the Deaf and Blind

(10) UDOH -- Utah Department of Health

(11) Vision Screening School Vision Screening programs are an efficient and cost-effective method to identify children with significant visual impairment so that a referral can be made to an appropriate eye care professional for further evaluation and treatment. School Vision Screenings must use devices and procedures approved by the Division and UDOH. The procedures for conducting screening may include, age or grade levels to be screened, tests to be used, criteria for referral and documentation of findings.

 

R384-201-3. Purpose.

The purpose of school based vision screening is to set standards and procedures for vision screening for students in public schools. This is necessary to detect vision difficulties in school age children in public schools so that follow-up for potential concerns may be done by the child's parent or guardian. Vision screening is not a substitute for a complete eye exam and vision evaluation by an eye care professional.

 

R384-201-4. Students Eligible for Free Screening.

The following students in an LEA may receive free vision screenings to include: distance visual acuity and other age appropriate tests that may detect visual problems upon request.

(1) Students entering pre-kindergarten, kindergarten and any student age eight and under entering school for the first time in Utah;

(2) Vision screening may be conducted for all school age children in grades pre-kindergarten through 12. The UDOH and the Division recommend screening students every other year after pre-kindergarten and kindergarten screenings, to include grades 1, 3, 5, 7, and 9 or 10 and annually for students with hearing impairment and any student referred by school personnel, parent or self to rule out vision as a reason for learning problems;

(3) Tenth grade students may be screened as part of their driver's education class; and

(4) Students who are currently receiving services from the Utah Schools for the Deaf and Blind (USDB) or LEA vision staff who have a diagnosed significant visual impairment will be exempt from screening.

 

R384-201-5. Required Screening.

Required screening for students identified with disabilities in an LEA are as follows:

(1) Vision issues have to be ruled out as reasons for learning problems before Specific Learning Disability can be used as eligibility criteria and

(2) Every three years, a student must be reevaluated for eligibility for special education in all areas of suspected disability, including vision.

 

R384-201-6. Proof of Screening.

Certificate or health form from a licensed physician, nurse practioner, eye care professional documenting a visual screening or examination given within one year of entering a public school are acceptable for school entry. All children age eight and under entering a public school for the first time without proof of screening mentioned above, may be screened during that school year by a trained vision screener.

 

R384-201-7. Training of Screeners.

(1) A training session shall be provided by the LEA to all volunteer vision screeners prior to the start of annual vision screenings.

(2) Trainings in compliance with Division materials should be provided by the LEA.

(3) The Department of Health in collaboration with the Division shall provide train the trainer vision screening training materials.

(4) Training vision screening materials will be shared with groups that provide free vision screening services in Utah schools.

 

R384-201-8. Screening.

(1) Screenings are to be performed following criteria developed by the UDOH in collaboration with the Division.

(2) It is recommended that vision screenings are done early in the school session to provide time in that school year for adequate referral and follow-up to be done.

(3) Parents/legal guardian of a child have the right not to participate in vision screening due to personal beliefs. All parents must be notified of scheduled vision screenings by the public school to provide an opportunity to opt out of screening for their child utilizing the vision screening exemption form, available at the public school, to document a personally held belief.

(4) A public school staff member should be present at all times during vision screenings performed by any volunteer(s) including those done by an eye care professional. If the school nurse is not present, the school nurse should be available for consultation and re-screening.

(5) Screenings are to be done using material and procedures approved by the UDOH in collaboration with the Division. Standards and procedures are based on guidance of American Academy of Pediatrics and the American Academy of Ophthalmology and National School Nurse Association.

(6) An eye care professional providing vision care to private patients may participate as a screener in a free vision screening program for students nine years of age or older.

(a) An eye care professional screener may not market, advertise or promote their business in conjunction with the free screening at public school.

(b) The eye care professional will provide results of vision screening to public school in a format (paper or electronic) as required by the Division.

(7) Any group that provides free vision screening services in the LEA will provide results of vision screening to the public school on forms required by the Division.

 

R384-201-9. Documentation and Follow-up.

All vision screening findings are to be documented in the student's permanent school record. Screening failures and follow-up results for students age eight and under, who are entering school for the first time in this state, are to also be reported to the Division by the LEA.

Reported information to the Division shall include:

(1) The LEA shall report to the division students who fail vision screening and referral follow-up results for children age eight and under, who are entering school for the first time in this state.

(2) Follow up information from an eye examination referral if available may be included with written permission obtained by the public school from the parent or guardian permission;

(3) Follow-up results and screening findings are to be documented in a format approved by the UDOH in collaboration with the Division;

(4) Screening results and follow-up information shall be sent to the Division on or before June 15 for all screenings performed during that school year;

(5) The Division is responsible to maintain a state database/registry only accessible by authorized Division staff of students who fail vision screening and who are referred for follow-up.

(6) In the interest of family privacy, the Division shall not contact a parent or guardian for information related to follow-up referral for professional eye examination unless assistance is requested in writing by the LEA.

 

R384-201-10. Requirements for Referral.

(1) Children who fail initial age appropriate school vision screening may be re-screened by a school nurse to confirm results before notification to student's parent or guardian of any impairment disclosed by the vision screening recommending further evaluation by an eye care professional. If the screening of a child 9 or older was administered in the public school by an eye care professional, the school nurse does not have to rescreen.

(2) The public school shall notify, in writing within 30 days from vision screening, a student's parent or guardian of any impairment disclosed by the vision screening recommending further evaluation by an eye care professional.

(3) An LEA may provide information to a parent or guardian of availability of follow up vision services for students.

(4) A student diagnosed by an eye care professional with a significant visual impairment shall be referred to the LEA vision consultant or teacher of the visually impaired prior to referral to the USDB.

 

R384-201-11. Photoscreening.

Preschool, kindergarten children, and special education students who are not candidates for regular vision screening may be screened by a school nurse using a sure sight scanner,another device approved by the Division or by Division staff with a photo screening type device. The Division is available for assistance and consultation for photo screening. Prior to photo screening by the Division or other outside agencies approved by the Division, the public school shall obtain written permission from the parent or guardian.

References:

National Association of School Nurses (2006) Vision Screening, schools.

S. Proctor (2005) To See or not to See screening the Vision of Children in School. National Association of School Nurses.

Pediatrics Vol. 111 No.4 April 2003, pp. 902-907 at 2003 American Academy of Pediatrics ICPC-2 Category F.Eye.]

R384-201-1. Authority.

(1) This rule is authorized by section 53G 9-404 and 26-1-30 (33).

(2) The Department of Health is authorized under the rule to set standards and procedures for vision screening required by this chapter, which shall include a process for notifying the parent or guardian of a student who fails a vision screening or is identified as needing follow-up care.

 

R384-201-2. Definitions.

(1) "Eye care professional" means an ophthalmologist or optometrist.

(2) IEP means an Individualized Education Plan.

(3) "Instrument based screening" means an automated screening technique that facilitates vision screening in students who are difficult to screen such as children with developmental delays.

(4) LEA means local education agency.

(5) "Screening certificate" means written documentation of vision screening or comprehensive eye examination by a health care professional as defined in 53G-9-404 (1)(a)done within one year of entering a public school.

(6) "Significant visual impairment" means a visual impairment severe enough to interfere with learning. The term is the designation required for a child to be eligible for services from a teacher of students with visual impairments in an LEA or USDB.

(7) "Screener" means those trained to support vision screening programs for students.

(8) USDB means Utah Schools for the Deaf and Blind.

(9) UDOH means Utah Department of Health.

(10) "Vision Screening" means a way to identify students with visual impairment.

 

R384-201-3. Purpose.

The purpose of school-based vision screening is to set standards and procedures for vision screening for students in public schools. This is necessary to detect vision difficulties in students so that follow-up for potential concerns may be done by the student's parent or guardian. Vision screening is not a substitute for a complete eye exam and vision evaluation by an eye care professional.

 

R384-201-4. Free Screening.

The following students in an LEA shall receive free vision screenings to include tier 1 screening.

(1) Vision screening shall be conducted for all students in grades pre-kindergarten, kindergarten, 1, 3, 5, 7 or 8, and 9 or 10 and any student referred by school personnel, parent or guardian or self to rule out vision as an obstacle to learning;

(2) Tenth grade students may be screened as part of their driver education class; and

(3) Students who are currently receiving services from USDB or LEA vision specialist who have a diagnosed significant visual impairment will be exempt from screening.

(4) Students may be referred for mandatory or optional tier 2 vision screening under the following circumstances in (a) and (b).

(a) Mandatory tier 2 screening may be done for students requiring education intervention such as special education referral or failing benchmark reading assessment as defined by R277-404.

(b) Optional tier 2 vision screening may be done based on parent or teacher concern.

(c) Students failing a tier 1 screening who have been referred to an eye care professional are not required to complete a tier 2 screening.

(d) Instead of performing a tier 2 vision screening, the LEA may automatically refer the student being referred to a tier 2 vision screening to an eye care professional.

(e) If the LEA does not have a school nurse or other approved tier 2 screener, the student being referred for a tier 2 vision screening should be automatically referred to an eye care professional.

 

R384-201-5. Required Screening for Students with an Individualized Education Plan.

Required screening for students identified with an IEP in an LEA are as follows:

(1) Vision issues have to be ruled out as an obstacle to learning before Specific Learning Disability can be used as eligibility criteria and

(2) Every three years, a student must be reevaluated for eligibility for special education in all areas of suspected disability, including vision.

 

R384-201-6. Proof of Screening.

Certificate or health form documenting a vision screening or examination given within one year of entering a public school are acceptable for school entry. All students less than age 9 entering a public school in Utah for the first time without proof of screening mentioned above, shall be screened during that school year.

 

R384-201-7. Training of Screeners.

(1) The LEA shall provide training annually to all vision screeners prior to the start of vision screenings.

(a) The school nurse shall provide training shall be provided to the vision screeners; or

(b) Vision screeners shall view the online module developed by UDOH referred to in 53G-9-404 (4)(b).

(2) The LEA will provide trainings in compliance with UDOH materials.

(3) The LEA will share vision screening training materials with qualified outside entities that provide free vision screening services in Utah schools.

(4) UDOH will create online training modules on:

(a) Tier 1 vision screening; and

(b) Training for tier 1 vision screeners; and

(c) Tier 2 vision screening for school nurses or other approved tier 2 screeners.

 

R384-201-8. Screening.

(1) Screenings are to be performed following criteria developed by UDOH.

(2) Screeners should do vision screenings early in the school session to provide time in that school year for adequate referral and follow-up to be done.

(3) A Parent or guardian of a student has the right not to have their student participate in vision screening. All parents or guardians must be notified of scheduled vision screenings by the public school to provide an opportunity to opt out of screening for their student. Parent or guardian choosing to opt out of vision screening for their student must do so annually and in writing.

(4) A public school staff member should be present at all times during vision screenings including those done by qualified outside entities.

(5) Screenings are to be done using material and procedures approved by UDOH. Standards and procedures are based on recommendations of American Academy of Pediatrics, the American Academy of Ophthalmology, the American Optometric Association, the National Center for Children's Vision & Eye Health, and National School Nurse Association.

(6) School vision screening is comprised of tier 1 and tier 2 screening.

(a) Tier 1 vision screening is a lower-level vision screening such as basic distance vision screening.

(b) Tier 2 vision screening is a higher-level evaluation that should include screening of distance and near vision. It may also include eye focusing or tracking problems, color screening, and screening for convergence insufficiency.

(i) The approved tier 2 screener may automatically refer the student to an eye care professional in lieu of performing the tier 2 screening.

(ii) If the LEA does not have an approved tier 2 screener the LEA should automatically refer the student to an eye care professional.

(7) Approved vision screeners include the following:

(a) Approved tier 1 vision screeners can be school nurses, qualified outside entities, trained volunteers, or health care professionals as defined in 53G-9-404 (1)(a) who have completed UDOH training for tier 1 vision screening.

(b) Approved tier 2 vision screeners can only be school nurses or health care professionals as defined in 53G-9-404 (1)(a) who have completed UDOH training for tier 2 vision screening.

(c) Persons assisting with vision screening:

(i) May not profit financially from school vision screening; and

(ii) May not market, advertise, or promote a business in connection with assisting with vision screening.

(8) Any qualified outside entity that provides free vision screening services in the LEA will provide results of vision screening to the public school.

(9) Students who are not candidates for regular vision screening may be screened using an approved instrument-based screening device. Only devices approved by UDOH should be used for screening, and then only when screening with a chart is not an option. Devices are not a substitute for clinical judgement and a visual acuity test.

(10) The LEA shall document all vision screening results including referrals and follow-up results in the student's permanent school record.

 

R384-201-9. Requirements for Referral.

(1) A school nurse may rescreen students who fail initial age appropriate school vision screening to confirm results before notification to student's parent or guardian of any impairment disclosed by the vision screening recommending further evaluation by an eye care professional.

(2) The LEA shall notify, in writing within 30 days from vision screening, a student's parent or guardian of any impairment disclosed by the vision screening recommending further evaluation by an eye care professional.

 

R384-201-10. Symptoms Questionnaire.

(1) The UDOH will provide schools a vision symptoms questionnaire that includes questions for classroom teachers to potentially identify eye focusing or tracking problems as well as convergence insufficiency. The UDOH will update the questionnaire as needed.

(2) For students who fail to achieve benchmark status on the benchmark reading assessment in grades 1-3:

(a) The LEA shall notify the student's teacher within 30 calendar days of student performance on the benchmark reading assessment.

(b) Teachers must complete the vision symptoms questionnaire within 45 calendar days of the administration of the assessment and submit to the school nurse.

(c) Teachers need only complete the vision symptoms questionnaire once per school year.

(d) School nurses or other approved tier 2 vision screeners shall use the vision symptoms questionnaire to perform a secondary assessment and/or refer to an eye care professional.

(3) For students who are being referred to special education for a suspected disability affected by vision difficulties:

(a) Teachers must complete the vision symptoms questionnaire and submit to the school nurse.

(b) School nurses or other approved tier 2 vision screeners shall use the vision symptoms questionnaire to perform a secondary assessment and/or refer to an eye care professional.

(4) For students who are being referred by parent or guardian for vision concern:

(a) Parent or guardian should complete the vision symptoms questionnaire and submit to the school nurse.

(b) School nurses or other approved tier 2 vision screeners shall use the vision symptoms questionnaire to perform a secondary assessment and/or refer to an eye care professional.

 

R384-201-11. Aggregate Reporting Requirements.

(1) All LEAs shall report aggregate numbers annually to UDOH to include:

(a) Total number of students receiving tier 1 vision screening; and

(b) Total number of students referred to an eye care professional following a tier 1 vision screening; and

(c) Total number of students referred to school nurse for tier 2 screening; and

(d) Total number of students referred to an eye care professional following a tier 2 vision screening; and

(e) Other information as requested by UDOH.

(2) This report may be submitted on the annual vision screening report, or as part of the annual school health workload census, and shall be due on or before June 30 of each year.

(3) No personally identifiable information will be collected.

 

KEY: eye exams, school vision, vision evaluations

Date of Enactment or Last Substantive Amendment: [July 1, 2013]2019

Notice of Continuation: June 7, 2018

Authorizing, and Implemented or Interpreted Law: [53A-11-203]53G-9-404