SIGNED FINAL Prevent Blindness Wisconsin and Sauk County Health Department 1-18-2024

By signing below, I understand the following conditions of the partnership between Prevent
Blindness Wisconsin (PBW) and Sauk County Health Department (SCHD):
PBW will:
• Enroll and provide access for SCHD staff to PBW’s online Adult Vision Screening Risk
Assessment Training video.
• Conduct Adult Vision Health Risk Assessment skills check and check-in meeting with
SCHD staff.
• Conduct quarterly check-in meetings with SCHD staff.
• Provide SCHD with PBW online Adult Vision Health Risk Assessment link for clients
enrolled in SCHD Community Care Program and additional SCHD Community Programs.
• Monitor online Adult Vision Health Risk Assessment submissions and share with SCHD
staff.
• Collect and track online Adult Vision Health Risk Assessment submissions via PBW’s
Salesforce Database System.
• Collect, review, and communicate with SCHD on client submissions of Adult Vision Care
Voucher Applications for the VSP Vision Care Voucher Program.
• Communicate with SCHD clients and SCHD staff on the status of VSP Vision Care
Voucher Program (approval, denials, or more information needed to process voucher
application).
• Conduct outreach to local vision clinics to raise awareness of current partnership with
SCHD and the need among Sauk County adults to access vision care.
o Donated eye exams/glasses
o Acceptance and use of VSP Vision Care Voucher Program
o Involvement in PBW Adult Vision Health Program
• Provide SCHD lead, Jessie Phalen, with Prevent Blindness Wisconsin’s Adult Follow-Up
Manual to expand vision health resources in the SCHD and to assist clients with their
vision health needs, respectively.
• Provide ongoing consultation and support to SCHD staff with adult vision health
questions, follow-up care support, VSP Vision Care Voucher Program, client education,
and resource guidance.
• Provide adult vision health educational resources to SCHD to display and offer in the
health department and to disseminate to clients.
• Provide clients accessing vision care with an ‘Adult Success Story’ form to submit to
PBW and SCHD.

SCHD will:
•  Participate in PBW's online Adult Vision Screening Risk Assessment Training video.
•  Schedule and participate in a skills check (for the adult vision health risk assessment) and 
check-in with PBW staff.
•  Participate in quarterly check-in meetings with PBW staff.
•  Link PBW's online Adult Vision Health Risk Assessment on SCHD's website for clients to access 
and use.
o The link to PBW's online Adult Vision Health Risk Assessment can also be offered in SCHD's 
newsletters and via different methods of communication/advertisement with current clients, 
community members and additional community agencies.
•  Communicate and disseminate online Adult Vision Health Risk Assessment with clients in the 
Community Care Program and additional Community Programs through SCHD.
•  Collect Adult Vision Health Risk Assessments from PBW staff on client online submissions.
•  Coordinate and assist referred clients from online Adult Vision Health Risk Assessment on 
eligibility for the VSP Vision Care Voucher Program.
•  Assist eligible clients with the application process for the VSP Vision Care Voucher Program 
(application and proof of income for clients).
•  Disseminate shared vision health resources with clients.
•  Assist with providing follow-up, education, and resources to clients who cannot manage 
scheduling and making eye doctor appointments on their own or have questions on their next steps to 
vision care.
•  Attempt to provide PBW with at least one "Adult Success Story'' including a photo and a quote 
from a client that participated in the VSP Vision Care Voucher Program, with client consent.
•  Share feedback, successes, and challenges with PBW in order to allow the partnership to grow and 
improve over time.
*We acknowledge events that take place within the community can be subject to change.