Each:
shall report in writing, on forms prescribed by the office of the secretary, not more than ten (10) days after diagnosis, to the office of the secretary, the name, age, and address of each person diagnosed by the physician or optometrist as being blind (as defined under 42 U.S.C. 416(i)) or having visual impairment of a degree to interfere with the person's functioning in school, employment, or other activities of daily living.
IC 12-12-9-1