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CSWIP Vision Certificate Form

The document outlines the vision requirements for an initial or renewal certification. It requires (1) near visual acuity of reading Jaeger J1 letters at 30 cm in at least one eye, (2) far vision acuity of at least 20/40, and (3) ability to differentiate colors on a test. The examination must be administered by an optometrist, medical doctor, registered nurse, or certified physician's assistant and certify that the applicant meets the criteria.

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Lalit Bom Malla
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Download as PDF, TXT or read online on Scribd
197 views

CSWIP Vision Certificate Form

The document outlines the vision requirements for an initial or renewal certification. It requires (1) near visual acuity of reading Jaeger J1 letters at 30 cm in at least one eye, (2) far vision acuity of at least 20/40, and (3) ability to differentiate colors on a test. The examination must be administered by an optometrist, medical doctor, registered nurse, or certified physician's assistant and certify that the applicant meets the criteria.

Uploaded by

Lalit Bom Malla
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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VISIONCERTIFICATE

GENERAL:
Initialexaminationisrequired,withorwithoutcorrectivelenses,toprove:
1. Unaidedorcorrectednearvisualacuityinatleastoneeyeshallbesuchthatthecandidateiscapableof
readingN4TimeRomantypeorJaegerJ1atadistanceofnotlessthan30cmonastandardreadingtest
chart.
2. Farvisionacuityof20/40orbetterand
3. Colorperceptiontestforred/greenandblue/yellowdifferentiation

Forrecertification,theexaminationisrequiredtoprovenearvisualacuityinatleastoneeyeshallbesuchthatthe
candidateiscapableofreadingN4TimeRomantypeorJaegerJ1atadistanceofnotlessthan30cmonastandard
readingtestchart.

Thiscertificationwillbevalidonlyifsignedbyoneofthefollowing:
OptometristMedicalDoctorRegisteredNurseCertifiedPhysiciansAssistant
ASNT/SNTTC1aLevelIIIANSIN45.2.6LevelIII
APPLICANTSINFORMATION:
Name:

Signature:

EXAMINERSINFORMATION:
PrintedName:
Profession:
OptometristMedicalDoctorRegisteredNurseCertifiedPhysiciansAssistant
ASNT/SNTTC1aLevelIIIANSIN45.2.6LevelIII

I,______________________,certifythatIhaveadministeredthevisionexamination(s)totheapplicant
(PrintedName)
mentionedabove.

SignatureofExaminerandDate:

ProfessionalLicenseNo.:

Address:

TelephoneNumber

ProfessionalStamp:

EXAMINATIONRESULT(TobecompletedbyExaminer)

FarVision20/40Minimum
NearVisionJaegerJ1lettersat30cm
ColorPerceptionPseudoisochromaticPlates
Red/GreenDifferentiation
Blue/YellowDifferentiation
Comments:

MeetswithoutEyeCorrection

MeetswithEyeCorrection

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