Vision Certificate printable pdf download

Vision Certificate

VISION CERTIFICATE

GENERAL:

Initial examination is required, with or without corrective lenses, to prove:

1. Unaided or corrected near visual acuity in at least one eye shall be such that the candidate is capable of

reading N4 Time Roman type or Jaeger J1 at a distance of not less than 30 cm on a standard reading test

chart.

2. Far vision acuity of 20/40 or better and

3. Color perception test for red/green and blue/yellow differentiation

For re‐certification, the examination is required to prove near visual acuity in at least one eye shall be such that the

candidate is capable of reading N4 Time Roman type or Jaeger J1 at a distance of not less than 30 cm on a standard

reading test chart.

This certification will be valid only if signed by one of the following:

Optometrist Medical Doctor Registered Nurse Certified Physician’s Assistant

ASNT/SNT‐TC‐1a Level III ANSI N45.2.6 Level III

APPLICANT’S INFORMATION :

Name:

Signature:

EXAMINER’S INFORMATION:

Printed Name:

Profession:

Optometrist Medical Doctor Registered Nurse Certified Physician’s Assistant

ASNT/SNT‐TC‐1a Level III ANSI N45.2.6 Level III

I, ______________________, certify that I have administered the vision examination (s) to the applicant

(Printed Name)

mentioned above.

Signature of Examiner and Date:

Professional License No.:

Address:

Telephone Number

Professional Stamp:

EXAMINATION RESULT (To be completed by Examiner)

Meets without Eye Correction

Meets with Eye Correction

Far Vision – 20/40 Minimum

Near Vision – Jaeger J1 letters at 30 cm

Color Perception Pseudoisochromatic Plates

•

Red / Green Differentiation

•

Blue / Yellow Differentiation

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Vision Certificate