Eye Exam Form - Acct
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1Eye Examination:
The following three sections are to be completed by the eye examiner
1. PLEASE PRINT CLEARLY
Date of Exam: ______________________
Applicant Name:
Examiner Name:
Phone Number:
Country: ___________________________
Examiner Address:
:
City:
ST:
Z
IP
E
(please check only one):
XAMINER PROFESSIONAL STATUS
Ophthalmologist
Optometrist
Medical Doctor
Registered Nurse
Certified Physician’s Assistant
Examiner Signature: ______________________________ License
Qualification
: ______________________
/
#
2. VISION ACUITY RESULTS:
Please verify the customer’s close vision acuity to Jaeger J2 (or equivalent) specifications at a distance of 20 inches
or greater:
(please check one of the following)
Both eyes require corrected vision to J2.
Only one eye needs corrected vision.
No correction is required.
3. COLOR PERCEPTION RESULTS:
Through a color perception examination, is the applicant colorblind? (please check one of the following).
NO, applicant is not color blind
YES, applicant is color blind ( A letter from the employer’s supervisor stating acknowledgement of this results is required bef ore testing)
If Additional Space is Needed, Use Blank Paper and Attach it to this Form
I hereby certify that the above information is true and correct. I have read the current Code of Ethics
and agree to follow it in the discharge of my duties. I understand that any false statements will
disqualify me for ACCT certification. I will provide documentation for both education and industry
experience in the challenge course industry along with this application. I will provide a copy of my
current Level I certificate or minimum documentation of experience if I plan to sit for a Level 2 exam.
Signature of Applicant
Date
Rev. 10/22/12
ICEC
ED.
Date
For Office Use Only
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Parent category: Medical