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Vision Format

This document outlines the requirements for a vision certificate general. An initial examination is required to prove (1) near vision acuity of 20/40 or better at 12 inches, (2) far vision acuity of 20/40 or better, and (3) color perception testing. For annual recertification, only near vision acuity needs to be proven. This certificate is valid for 6 months from the date of eye exam and must be signed by an optometrist, medical doctor, registered nurse, or certified examiner. The document also includes sections for applicant information, test/examination results, doctor/examiner information, and signature.

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Subramanian Vaithilingam
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251 views

Vision Format

This document outlines the requirements for a vision certificate general. An initial examination is required to prove (1) near vision acuity of 20/40 or better at 12 inches, (2) far vision acuity of 20/40 or better, and (3) color perception testing. For annual recertification, only near vision acuity needs to be proven. This certificate is valid for 6 months from the date of eye exam and must be signed by an optometrist, medical doctor, registered nurse, or certified examiner. The document also includes sections for applicant information, test/examination results, doctor/examiner information, and signature.

Uploaded by

Subramanian Vaithilingam
Copyright
© Attribution Non-Commercial (BY-NC)
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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VISION CERTIFICATE GENERAL

Initial examination is required, with or without corrective lenses, to prove (1) near vision acuity of Snellen English or equivalent Jaeger J-1 at 12 inches; (2) far vision acuity of 20/40 or better and (3) color perception test for red/green and blue/yellow differentiation. For annual re-certification, the examination is required to prove near vision acuity or Snellen English or equivalent Jaeger J-1 at 12 inches. This certificate is valid for 6 months only from the date of eye test. This certification will be valid only if signed by one of the following: Optometrist Medical doctor Registered nurse Assistant ASNT/SNT-TC-1a Level III ANSI N45.2.6 Level III Certified Physician's

APPLICANT INFORMATION (To be completed by Candidate)


Candidate Name: Date of eye test Candidate Signature:

TEST/EXAMINATION RESULTS (To be completed by Doctor / Examiner)


Meets Without Eye Correction (1) (2) (3) Far Vision 20/40 Minimum Near Vision --Jaeger J-1 letters at 12 inches Color Perception Pseudoisochromatic Plates (a) Red/Green Differentiation Meets With Eye Correction

(b) Comments:

Blue/Yellow Differentiation

DOCTOR / EXAMINER INFORMATION (To be completed by Doctor / Examiner)


I administered the vision examination(s) to the applicant/candidate The examiner's professional title is: Optometrist Certified Physician's Assistant Medical Doctor ASNT/SNT-TC-1a Level III Registered Nurse ANSI N45.2.6 Level III

Name of the Docto r/ Examiner with stamp :

Signature of Doctor / Examiner:

Professional Address:

Telephone Number:

State License Number:

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