Dd Form 2489 - Dod Medical Examination Review Board (Dodmerb) Farnsworth Lantern And Red/green Color Vision Tests
Download a blank fillable Dd Form 2489 - Dod Medical Examination Review Board (Dodmerb) Farnsworth Lantern And Red/green Color Vision Tests in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Dd Form 2489 - Dod Medical Examination Review Board (Dodmerb) Farnsworth Lantern And Red/green Color Vision Tests with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2DOD MEDICAL EXAMINATION REVIEW BOARD (DODMERB)
OMB No. 0704-0396
FARNSWORTH LANTERN AND
OMB approval expires
RED/GREEN COLOR VISION TESTS
Nov 30, 2009
The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering
and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information,
including suggestions for reducing the burden, to the Department of Defense, Executive Services Directorate, Information Management Division, 1155 Defense Pentagon, Washington, DC 20301-1155
(0704-0396). Respondents should be aware that notwithstanding any other provision of law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not
display a currently valid OMB control number.
PLEASE DO NOT RETURN YOUR FORM TO THE ABOVE ORGANIZATION. RETURN COMPLETED FORM TO DODMERB/DR, 8034 EDGERTON
DRIVE, SUITE 132, USAF ACADEMY CO 80840-2200.
PRIVACY ACT STATEMENT
AUTHORITY: Title 10, USC 133, 3012, 5031, 8013, and Executive Order 9397.
PRINCIPAL PURPOSE: To determine medical acceptability or update a medical file as part of the application process to a United States
Service Academy, Reserve Officer Training Corps (ROTC) Scholarship Program, or the Uniformed Services University of the Health Sciences
(USUHS).
ROUTINE USES: This information may be disclosed to the Coast Guard Academy and Merchant Marine Academy for applications to their
Academies.
DISCLOSURE: Voluntary; however, failure to furnish the requested information will impede the selection process and hamper your candidacy.
Use of the Social Security Number (SSN) is used for positive identification of records.
1. NAME OF APPLICANT (Last, First, Middle Initial)
2. SOCIAL SECURITY NUMBER
FARNSWORTH LANTERN
IMPORTANT: This test MUST be performed or verified and countersigned by an optometrist, flight surgeon,
or by a physician experienced in performing the FALANT test.
INSTRUCTIONS TO EXAMINERS
READ REVERSE SIDE OF THIS FORM BEFORE ADMINISTERING TEST.
Indicate by letter the applicants' responses,
reminding them at the beginning of the test that there are only three responses: Red, Green, or White.
NUMBER OF
G/R
W/G
G/W
G/G
R/G
W/R
W/W
R/W
R/R
ERRORS PER RUN
1st RUN
2nd RUN
3rd RUN
NOTES: Farnsworth Dichotomous or other variations are not acceptable.
The examiner must alter the sequence of lights on the 2nd and 3rd runs.
RED/GREEN COLOR VISION TEST
3. I CERTIFY THAT APPLICANT
CAN
CANNOT
DISTINGUISH AND IDENTIFY OBJECTS THAT ARE BRIGHT RED AND BRIGHT GREEN.
5. FACILITY NAME AND COMPLETE
4. EXAMINER
ADDRESS (Street, City, State, ZIP Code)
NAME (Last, First, Middle Initial)
TITLE
EXAMINER SIGNATURE
DATE
PHYSICIAN SIGNATURE
DATE
(YYYYMMDD)
(YYYYMMDD)
DD FORM 2489, MAR 2008
PREVIOUS EDITION IS OBSOLETE.
Reset
Adobe Professional 7.0
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical