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CISS Program Registration

More Information

The Foundation for Vision Therapy Awareness (formerly Building Vision) is conducting some research.  It’s really very simple.  Below is a digital download of the CISS (Convergence Insufficiency Symptom Survey).  We will pay an optometrist $5 for every CISS filled out for patients between 8-18 years of age. The easiest way to participate is to add the CISS to the history forms that are filled out at a patient's comprehensive eye exam.  


Why are we doing this?


We believe that this research is really a win-win for everyone.  We know it can be a helpful tool to identify more children who struggle with binocular vision problems.  It will also provide our organization with valuable insight into prevalence for binocular vision problems and referral patterns. 




  • All children aged 8 through 18 are to receive the Convergence Insufficiency Symptom Survey  

  • Please ensure that no protected health information (i.e. patient’s name, date of birth) is placed on the CISS form or that it is deleted upon submission.

  • Identify those children with a CISS score of 16 or higher.  Additional testing may be done, but does not have to be done.  Referrals based on symptoms are sufficient. For example, if a patient is complaining of double vision when reading, this is sufficient information to relay to a VT provider in your area.

  • You and your staff will be given access to a Google Drive folder.  Once a month, you will upload scanned copies of the filled out CISS


Once a month, a check will be sent for $5 for every CISS that has been completed and uploaded.  We really appreciate your help with this program.  Please contact us if you ever have any questions.

Next Steps?

  • Please fill out the registration form on our website above.

  • Below you will find a copy of the CISS and a referral form that you can use to refer patients to a VT provider in your area. 

Digital Copy of the CISS (Convergence Insufficiency Symptom Survey)

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Digital Copy of Referral Form

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