Visual Acuity Record

ADVERTISEMENT

VISUAL ACUITY RECORD
Name of Applicant__________________________________________________________________________
Social Security No. _____________________________Certificate No (if certified) ______________________
Location and Date of CWI/SCWI exam (if testing) _______________________________________
TO ALL CERTIFICATION EXAMINATION CANDIDATES:
Please use the services of an Ophthalmologist, Optometrist, Registered Nurse, or certified Physician's Assistant
to administer your required eye examination. The examination must occur within the 7 months prior to the
scheduled date of the candidate’s welding inspection examination or re-certification anniversary date. Please
send the original form completed by the eye examiner to AWS, and keep a copy for your files.
All candidates must pass an eye examination, with or without corrective lenses, to prove near vision acuity on
Jaeger J2 at 12” – 17” inches. Shall take a color perception test. Eye examination results shall be submitted on
forms furnished by the AWS Certification Department.
AWS will not accept a visual acuity record which does not comply with the requirements. AWS will not release
your test results without a completed visual acuity record on file. Applicants may submit completed visual acuity
records at the CWI exam location.
TEST RESULTS
Does the candidate possess near vision acuity of Jaeger J2 (letters .37mm in size) at a distance of 12” – 17” inches?
______Yes
______Yes, but with corrective lenses
Does the candidate possess color perception (using pseudoisochromatic plates)?
______Yes
______No
Does the candidate possess the ability to differentiate between red and green?
______Yes
______No
I certify that I, _____________________________________________, administered an eye examination to
(print name of eye examiner)
____________________________________________, on ___________________, which demonstrated the
(print name of applicant)
(mo/day/year)
vision capabilities indicated above.
Please identify your professional level by checking one of the following:
oOptometrist oMedical Doctor oRegistered Nurse oCertified Physician's Assistant
State License #________________________________________________
Professional Address___________________________________________
City, State, Zip _______________________________________________
Signature of Eye Examiner_______________________________________
Area Code/Telephone Number (_______)___________________________
Cert-Visual Acuity Record 06/13/2001

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go