FORM 4
Community/School Summary Form for Trichiasis Aboriginal Adults

State/Territory__________________________________________________________

Population Health Unit Region______________________________________________

Community/school_______________________________________________________

Date(s) of Screening _____________________________________________________

Form Completed by Name___________________________________ Date __________
Number of Aboriginal adults:
<30 years
30-49 years
50+ years
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Examined for trichiasis
With trichiasis
In the screening target group (i.e. number of Aboriginal adults in the screened age group in the communities/towns targeted for screening)
In the coumunity/school in the screened age group (from census data)
With trichiasis who were offered an ophthalmological consultation within 6 months of the previous screening
Please report the number of Aborginal adults who underwent trichiasis surgery in the previous year
<30 years
30-49 years
50+ years
malefemalemalefemalemalefemale