Standards › Standard 15 › Forms
Form · OPT-FRM-006 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 15 (Optical and Hearing), criterion 15.7
Purpose
Records each urgent eye or ear referral, the time it was made and that the patient reached care.
How to complete
- Record the sign and the time.
- Record the referral made.
- Confirm the patient reached care.
Checks
| Check | Entry |
|---|---|
| Presenting sign (sudden loss of vision or hearing, other) | Yes |
| Time recognised | Yes |
| Referred to (service) and time | Yes |
| Patient reached care (confirmed, date) | Yes |
| Recorded by | Yes |
Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO World report on vision (2019) and the WHO World report on hearing (2021). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)