Form Cg-719k - Medical Evaluation Report Page 6
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9Page 6 of 9 of CG-719K Rev. 01-09
Section V (a) – Visual Acuity
This section must be completed by the verifying medical practitioner, or any other healthcare provider to the satisfaction of
the verifying medical practitioner see encl
5 of NVIC 4-08.
Additional information must be reported in Section VII. If
corrective lenses are required to meet the standard, both corrected and uncorrected vision must be tested.
Distant Uncorrected
Distant Corrected To
Field of Vision
Normal
Right:
20
/
Right:
20
/
This applicant must have a 100-degree
horizontal field of vision.
Abnormal
Left:
20
/
Left:
20
/
Section V (b) – Color Vision
The following color sense testing methodologies are
Titmus Vision Tester / OPTEC 2000 – (No errors on six
acceptable:
plates)
AOC (1965) – (6 or fewer errors on plates 1-15)
Farnsworth Lantern (colored lights) Test per instruction
nd
AOC-HRR (2
Edition) – (No errors in test plates 7-11)
booklet.
Richmond (1983) – (6 or fewer errors)
Optec 900 (colored lights) Test per instruction booklet.
Ishihara pseudoisochromatic plates test, 14 plate (5 or
An alternative test approved by the Coast Guard
less errors), 24 plate (6 or less errors) 38 plate (8 or
(indicate test)
less errors)
The verifying medical practitioner must indicate test used and results (number of errors). Additional information must be
I
reported in Section VI
. Color sensing lenses (e.g. X-Chrome) are prohibited.
Color Vision:
Normal Color Vision
Abnormal Color Vision
Number of Errors _______________
Section VI – Hearing
Normal
Abnormal Hearing
Hearing Aid Required
If abnormal hearing or hearing aid required, perform audiogram or functional speech discrimination test.
An applicant with normal hearing does not need to complete either the audiometer test or the functional speech
discrimination test. The verifying medical practitioner, in consultation with any other healthcare provider he/she deems
appropriate, determines whether the audiometer and/or functional speech discrimination tests are necessary. If hearing is
abnormal or a hearing aid is required, refer to enclosure
(5) of NVIC 4-08
for guidance.
If audiometric testing is required, the audiometer test should include testing at the following thresholds, 500Hz, 1,000 Hz,
2,000 Hz and 3000 Hz. The frequency responses for each ear are averaged to determine the measure of an applicants
hearing ability. The Applicant should demonstrate an unaided threshold of 20dB in each ear.
I
Additional information must be reported in Section V I
.
500Hz
1,000Hz
2,000Hz
3,000Hz
Audiometer Threshold Value
Right Ear (Unaided)
Left Ear (Unaided)
Right Ear (Aided)
Left Ear (Aided)
Right Ear (Unaided):
%
Right Ear (Aided)
%
Functional Speech
Discrimination Test @ 55dB
Left Ear (Unaided):
%
Left Ear (Aided)
%
Applicant Name: _______________________________________
Date of Birth:____________________________
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