Spot Vision Screener Request Form

Email Address?(Required)

School District?(Required)

Individual Requesting Use of Device?(Required)

Check Out Date?(Required)

Return Date?(Required)

(Two weeks maximum, unless other arrangement made PRIOR to check out)

Individual Picking Up Device from the NWESD?(Required)

Signature required upon pickup.

Individual Has Received Proper Training in the Use of Device?(Required)

Yes

If no, we will provide basic training when that person picks up the Spot Screener.