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Director of Special Services 614-873-0845 Or mail to: JA Special Services Office 6440 Killbury-Huber Rd. Plain City, OH 43064 Doctor, please note NA (not applicable) beside any item below that is not included in your routine examination. Name of Student DOB Name of School Grade Parent/Guardian Exam Date OBJECTIVE FINDINGS A. Visual Acuity At Distance Without Rx: (R) 20/ At Near (L) 20/ (R) 20/ (L) 20/ With Old Rx: With New Rx: B. Binocular Status/Efficiency Add remarks when.

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