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UJ Duke Family Medicine & Community Health
Duke University School of Medicine
EMPLOYEE OCCUPATIONAL
HEALTH AND WELLNESS (EOHW)

Color Blind Screening

Please fill out completely. Both Applicant and Witness signatures are required.

Requirements
This screening requires an adult that is not color blind who can witness the test and sign above.

Instructions
Navigate to the color vision test site via the link bellow. Once on the site, bellow the introductory information, 12
boxes will appear that contain a number. Beneath the boxes enter the number you see in the space provided. Once
all of the questions have been answered, report the percentage of correctly answered questions above.

Click on web link (Ctrl+click) below to start the screening.

https://colormax.org/color-blind-test/

For Duke University and Duke Regional Employees

Please navigate to the secure portal https://duke.qualtrics.com/jfe/form/SV_9ZiDYxKsjI9eqJT and upload
your completed documents. You can also fax your documents to 919-385-7574.

Date _______________________

Duke University
Employee Occupational Health & Wellness
Phone 919-684-3136 option #2

Duke Regional Hospital

Employee Occupational Health & Wellness
Phone: 919-470-5350

On _______________________ (date) the Ishihara’s Tests for Color-Blindness was administered remotely to the
following individual and the test findings are indicated below:

Applicant Name: __________________________________________________

DOB: _______________________

Percent correct: _______

Applicant Signature: __________________________________________________

Witness Signature: __________________________________________________

Retain a copy of this document for your records.

P:\Common\Remote Clearance Forms\Current Individual Forms\Color Blind Screening V6.Docx