REPUBLIC OF KENYA ‘ ee MINISTRY OF HEALTH Ref: MOH/276B ASSESSMENT FORM FOR VISUAL IMPAIRMENTS IIKA Lever S Hospiry, DD/MM/YYYY gj iolos\iqe4q Ba “= Applicant Information for the purpose of reporting on Disability Assessment Chairperson a ember Kener Vane | 3426 co Member \ ~2 666 co Member Sh pele Kew! (Hd f {understand that giving false information is punishable by the laws of Kenya) Note: the committee should have a minimum of three MembersHISTORY i ASSISTIVE DEVICE MEDICAL HISTORY uw OCULAR HISTORY Bo Bituduers: a? to Conpenss tet! Right Eye Left Eye fae een Near Vision Test Present eae ceee cil ee m eyeball = optrarmnos = Squint oe = Anterior Chamber | Tearing = — Pupil ies aes Lids Perteus Pretent Lens —— | = Conjunctiva | Piyect | Pletet [ Funes —Impairment See | in Impairment a eee TEMPORARY O PERMANENT VERIFIED BY THE COUNTY DIRECTOR OF HEALTH Name. Date... Signature. ‘Any Possible Intervention Yes ee ystes Ubi hy cy eLwdt- ——— oe COUNTY DIRECTOR OF HEALTH OFFICIAL STAMP