Scribd Logo
Upload

Welcome to Scribd!

  • 185 views

    1224 Visual Acuity From

    Uploaded by

    reza khakshouri
    This document is a visual acuity form for AWS certification applicants. It must be completed by an eye examiner to verify the applicant's close vision acuity and color perception. The eye examiner must confirm the applicant can read Jaeger J2 letters at 12 inches or greater, with or without correction, and is not colorblind. The completed form must be submitted to AWS prior to the certification exam or within 60 days after to avoid voiding exam scores or applications.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    1224 Visual Acuity From

    Uploaded by

    reza khakshouri
    185 views1 page
    This document is a visual acuity form for AWS certification applicants. It must be completed by an eye examiner to verify the applicant's close vision acuity and color perception. The eye examiner must confirm the applicant can read Jaeger J2 letters at 12 inches or greater, with or without correction, and is not colorblind. The completed form must be submitted to AWS prior to the certification exam or within 60 days after to avoid voiding exam scores or applications.

    Original Description:

    1224 Visual Acuity From

    Copyright

    © © All Rights Reserved

    Available Formats

    PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document is a visual acuity form for AWS certification applicants. It must be completed by an eye examiner to verify the applicant's close vision acuity and color perception. The eye examiner must confirm the applicant can read Jaeger J2 letters at 12 inches or greater, with or without correction, and is not colorblind. The completed form must be submitted to AWS prior to the certification exam or within 60 days after to avoid voiding exam scores or applications.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    185 views1 page

    1224 Visual Acuity From

    Uploaded by

    reza khakshouri
    This document is a visual acuity form for AWS certification applicants. It must be completed by an eye examiner to verify the applicant's close vision acuity and color perception. The eye examiner must confirm the applicant can read Jaeger J2 letters at 12 inches or greater, with or without correction, and is not colorblind. The completed form must be submitted to AWS prior to the certification exam or within 60 days after to avoid voiding exam scores or applications.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    8669 NW 36 St, #130 Miami, FL 33166-6672

    (800) 443-9353 extension 273


    Email [email protected]

    VISUAL ACUITY FORM

    Member #: _______________ Online Order #: _______________ Site Code: _____________ Date: _________________

    Last Name: __________________________________ First Name: ______________________________ MI: ___________

    Applicant
    This form must be submitted for all SCWI/CWI/CAWI/CRI/CWEng applications ONLY.
    AWS will not release exam results, recertification results, or renewals without a completed Visual Acuity Record on file.
    IMPORTANT: This completed Visual Acuity Form must be sent to the AWS Certification Department prior to the exam, or no later than 60 days after
    the certification exam date. Form may be sent via fax, email, or mail. Applicants who have not fulfilled all requirements within 60 days after the
    certification exam date shall have scores and application voided, and may be in jeopardy of forfeiting application fees.

    Eye Examination
    Eye examinations shall be administered by an Ophthalmologist, Optometrist, Medical Doctor, Registered Nurse or Certified Physicians Assistant or by
    other ophthalmic medical personnel, and must include the state or province license number. Examinations shall be performed within (1) year of the
    certification examination date, or within (1) year of the certification expiration date for renewal or recertification.

    All applicants must pass an eye examination, with or without corrective lenses, to prove near vision acuity on Jaeger J2 at 12 in. or greater (30.5 cm).
    All applicants shall take a color perception test. Eye examination results must be documented on this Visual Acuity Record form supplied by the AWS
    Certification Department. No other forms will be accepted.

    1. The following must be completed by the eye examiner:


    A. Verify the customers close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater(30.5 cm) AWS Use
    (Check ONLY one of the following for each eye) Only
    OD OS
    Requires corrected vision to read Jaegar J2 at 12 in. or greater. W
    No correction is required to read Jaegar J2 at 12 in. or greater. O
    Unable to read Jaegar J2 at 12 in. or greater even with attempt at correction. NQ
    B. Through a color perception examination, is the applicant colorblind? AWS Use
    (Check ONLY one of the following for each eye) Only
    OD OS
    Customer IS NOT colorblind C
    Customer IS colorblind. B
    3. Examiners Contact Information (print clearly)

    Customer Name: Date of eye exam:


    Examiner Name: Phone Number:
    Examiner Address:
    City: State: Zip/Postal Code: Country:
    4. Examiner professional status (check only one)
    Ophthalmologist Optometrist Medical Doctor Registered Nurse Certified Physicians Assistant

    Examiner Signature: State/Prov. License number:

    Visual Acuity Form_1224 January 13, 2017

    You might also like