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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. 

 

Expectations:

 

  • 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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