Forms & Clinic Information

A Low Vision Collaboration Clinic (LVCC) is generally for children/students that can interpret eye charts (numbers, letters or pictures) and communicate what they are seeing to the doctor.

To schedule a Low Vision Collaboration Clinic (LVCC) or Low Vision Collaboration Clinic + (LVCC+):

1. Please contact your KSSB Field Service Specialist or Molly Reardoncreate new email, KLK Coordinator at (913) 309-7041opens phone dialer with questions and to discuss which type of Low Vision Clinic would be more appropriate.
2. Complete the Low Vision Collaboration Clinic (LVCC) or Low Vision Collaboration Clinic+ (LVCC+).
3. Email all required documents to Molly Reardoncreate new email.

ALL DOCUMENTS ARE DUE ONE MONTH BEFORE CLINIC DATE.

What Happens Next?

• The Regional Field Services Specialist will contact the doctor’s office to setup a date and time for the evaluations and then send you a Clinic Schedule for you to complete and return.
• Molly Reardon will upload the completed documents to KSSB’s KLK Database so that the doctor will have on-line access to prepare for the evaluation.
• After the evaluation, a report will be generated by the doctor and distributed to the TSVI/ECI to deliver to the family and school.
• KSSB will send an invoice to your district after completion of the LVCC or LVCC+ for the children/students assessed.  The invoice will be sent to the designated person indicated by you on the Contact Information Form. Services for birth-three will not be billed (do not fill out billing contact info).

If you have additional questions, please contact Molly Reardoncreate new email, KanLovKids Coordinator at (913) 309-7041opens phone dialer.

Please complete the following KanLovKids LVCC Forms.

• KLK Participation and Consent Form
• Contact Information Form for LVCC and LVCC+
• Student’s Eye Doctor Information Form
• Photograph and Media Release Form
• If you prefer, please print all KanLovKids LVCC Formsopens PDF file , fill them out, and email them to Molly Reardoncreate new email.

Fill this out only if KSSB Field Services Specialists requests it for the doctor Impact of Vision Impairment for Children (IVI-C for 12 to 18 years of age). This form should be completed online, as it will be automatically scored.

ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  (be sure to indicate if ASL or Spanish interpreter is needed).

BRING SAMPLES OF STUDENT’S WORKSHEETS, TEXTBOOKS, ETC.

A Low Vision Collaboration Clinic+ (LVCC+) is for infants, toddlers or school-aged children who have alternative communication and complex needs.

Information needed for Low Vision Collaboration Clinic+ are:

1. Please complete the follow KanLovKids LVCC+ forms:
   • Consent Form for Onsite Clinics OR Consent Form for Virtual Consultation.
   • Contact Information From for LVCC and LVCC+
   • Student’s Eye Doctor Information Form
   • Photograph and Media Release From
   • Child Family History Form
   • If you prefer, please print all KanLovKids LVCC+ Forms, fill them out, and email them to Molly Reardoncreate new email
     • Consent Form for Onsite Clinicsopens PDF file or Consent From for Virtual Consultationopens PDF file
     • Contact Information Form, Student’s Eye Doctor Form, Child/Family History Form, and Photograph and Media Release Formopens PDF file
2. Release form from Dr. Linda Lawrence’s officeopens PDF file (only needed for Dr. Lawrence’s clinics) Do not write KanLovKids on it.

ALL DOCUMENTS ARE  DUE ONE MONTH BEFORE CLINIC DATE  (be sure to indicate if ASL or Spanish interpreter is needed)

BRING SUPPORTED SEATING EQUIPMENT AND TRAVEL OR WHEELCHAIR TRAYS, ALONG WITH TOYS OR OBJECTS THE CHILD PREFERS.