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Vision Certificate Format

This document is a vision certificate that certifies an individual's vision meets certain requirements. The requirements include having near vision acuity of at least Jaeger J-1 at 12 inches, far vision acuity of at least 20/40, and the ability to differentiate between red/green and blue/yellow colors. The certificate must be signed by an optometrist, medical doctor, registered nurse, certified physician's assistant, or someone certified at ASNT/SNT-TC-1a Level III or ANSI N45.2.6 Level III to be valid. It requires the applicant and examiner to provide identifying information and certification that the applicant passed a vision exam meeting the stated requirements.

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2K views1 page

Vision Certificate Format

This document is a vision certificate that certifies an individual's vision meets certain requirements. The requirements include having near vision acuity of at least Jaeger J-1 at 12 inches, far vision acuity of at least 20/40, and the ability to differentiate between red/green and blue/yellow colors. The certificate must be signed by an optometrist, medical doctor, registered nurse, certified physician's assistant, or someone certified at ASNT/SNT-TC-1a Level III or ANSI N45.2.6 Level III to be valid. It requires the applicant and examiner to provide identifying information and certification that the applicant passed a vision exam meeting the stated requirements.

Uploaded by

Amit Sindhya
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Decibel Nde Inspections & Training Institute Vision Certificate

VISION CERTIFICATE

GENERAL
Initial examination is required, with or without corrective lenses, to prove (1) near vision acuity of Snellen English or
equivalent Jaeger J-1 at 12 inches; (2) far vision acuity of 20/40 or better and (3) color perception test for red/green and
blue/yellow differentiation.
For annual re-certification, the examination is required to prove near vision acuity or Snellen English or equivalent
Jaeger J-1 at 12 inches.
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 INFORMATION (To be completed by Candidate)


Candidate Date of Candidate
Name: Examination Signature:

EXAMINER INFORMATION (To be completed by Examiner)

I certify that Dr./Mr/Mrs administered the vision examination(s) to the applicant.


(Print or Stamp Examiner's Name)
The examiner's professional title is:

Optometrist Medical Doctor Registered Nurse Certified Physician's Assistant

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


Signature of Examiner:
Professional Address:

Telephone Number: State License Number:

TEST/EXAMINATION RESULTS (To be completed by Examiner)


Meets Without Eye Correction Meets With Eye Correction
Does Not Meet

(1) Far Vision – 20/40 Minimum

(2) Near Vision --Jaeger J-1 letters at 12 inches


(3) Color Perception Pseudoisochromatic Plates

(a) Red/Green Differentiation

(b) Blue/Yellow Differentiation  

Comments:

Document Ref: PD-C12 Issue: 05 Issue Date: 16-01-2016


This Form Need to be Submitted as a Requirement for Certification Programs at Decibel.

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