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Attachment 1 EYE Test Certification: Engineering Standards Manual OST220-03-01-ESM

This document is an eye test certification form for visual welding inspection. It records an individual's eye test results with and without corrective lenses for near and far distance vision in each eye. It also notes the type of eye test administered and whether the individual distinguished the appropriate number and range of color plates to verify normal color vision. The form must be signed by the examiner and responsible manager to certify vision requirements have been passed.

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249 views1 page

Attachment 1 EYE Test Certification: Engineering Standards Manual OST220-03-01-ESM

This document is an eye test certification form for visual welding inspection. It records an individual's eye test results with and without corrective lenses for near and far distance vision in each eye. It also notes the type of eye test administered and whether the individual distinguished the appropriate number and range of color plates to verify normal color vision. The form must be signed by the examiner and responsible manager to certify vision requirements have been passed.

Uploaded by

Reza
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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LANL Engineering Standards Manual OST220-03-01-ESM Chapter 13, Welding

GWS 1-11– Visual Welding Inspection and NDE Qualification Rev. 0, 8/16/04
Attachment 1, Eye Test Certification Eff. 12/1/04

ATTACHMENT 1
EYE TEST CERTIFICATION
NAME: EMPLOYEE Z No./(SSN if unavailable):

TEST WITHOUT CORRECTIVE LENSES NEAR DISTANCE FAR DISTANCE

1. RIGHT EYE O.D. (COVER LEFT EYE) _______________ ______________


2. LEFT EYE O.S. (COVER RIGHT EYE) _______________ ______________
3. BOTH EYES O.U. _______________ ______________

TEST WITH CORRECTIVE LENSES

TYPE OF CORRECTION USED (e.g., READING, BIFOCAL) : __________________________________________

NEAR DISTANCE FAR DISTANCE


1. RIGHT EYE O.D. (COVER LEFT EYE) _______________ ______________
2. LEFT EYE O.S. (COVER RIGHT EYE) _______________ ______________
3. BOTH EYES O.U. _______________ ______________
TYPE OF TEST
NEAR DISTANCE JAEGER OTHER _____________________________________
FAR DISTANCE SNELLEN OTHER _____________________________________
COLOR ISHIHARA PSEUDO-ISOCHROMATIC PLATES
HAS THE APPLICANT DISTINGUISHED THE APPROPRIATE RANGE AND NUMBER OF COLOR PLATES TO VERIFY
NORMAL COLOR VISION? YES NO

IF APPLICABLE, WHAT COLOR(S) IS THE APPLICANT DEFICIENT IN? ___________________________


REMARKS: ____________________________________________________________________________
_______________________________________________________________________________________.

I CERTIFY THAT THE RESULTS RECORDED ARE THOSE FROM THE EYE EXAMINATION ADMINISTERED TO:

Examiner Name: ______________________________________________ Z#: ______________________

Signed: _______________________ Title: _____________________ Date: ____________


Based on the recorded test results, the above applicant has satisfactorily passed the examination for vision
certification.

Signed ________________________________ Title: ______________________ Date: ____________


RESPONSIBLE MANAGER/LEVEL III

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