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0455e-2021-1 - Welding Inspector Visual Acuity Record-Fillable

This document outlines vision requirements for welding inspectors applying for or renewing certification. It includes sections for applicant identification, vision requirements, and a declaration from a medical examiner certifying the applicant's visual acuity meets or does not meet the standards.

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44 views1 page

0455e-2021-1 - Welding Inspector Visual Acuity Record-Fillable

This document outlines vision requirements for welding inspectors applying for or renewing certification. It includes sections for applicant identification, vision requirements, and a declaration from a medical examiner certifying the applicant's visual acuity meets or does not meet the standards.

Uploaded by

8nb9kdwg2m
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as PDF, TXT or read online on Scribd
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CWB Form 455E/2021-1

Welding Inspector Visual Acuity Record

SECTION 1: IDENTIFICATION OF APPLICANT (Please print):

Applicant's Name: Registration #:


Application for Certification Renewal of Certification
*Email:
*I understand that all official communication moving forward will be sent to me via electronic mail (email) and it is my responsibility to advise
the CWB Group of any changes in my email address.
initials

SECTION 2: VISION REQUIREMENTS:


Evidence of satisfactory vision, as determined by a medical professional, must be provided by all new applicants
and certified inspectors who are renewing their certification. The vision examination must have been
performed no more than 12 months from the date of receipt of this form by the CWB.

Near vision acuity shall permit reading a minimum of Jaeger number 1 or Times Roman N 4.5 or equivalent
letters (having a height of 1.6 mm) at not less than 30 cm with one or both eyes, either corrected or uncorrected.

Submission of a prescription for corrective lenses in lieu of this form is not acceptable.

SECTION 3: DECLARATION OF EXAMINER:


This is to certify that I, administered a test of visual acuity
Examiner's Name (please print)
to on
Applicant's Name (please print) Examination Date (MM / DD / YYYY)

I also certify that the applicant: (check applicable box)


Meets the vision requirements in Section 2 without correction
Meets the vision requirements in Section 2 with correction
Does not meet the vision requirements in Section 2

Check one of the following:


Optometrist Ophthalmologist Medical Doctor
Registered Nurse

Address:

Signature of Examiner: Tel. #:

FOR CWB USE ONLY:

Reviewed by: Date:

PLEASE ATTACH COMPLETED RECORD TO YOUR APPLICATION AND SEND TO THE CWB.
RETAIN A COPY FOR YOUR FILE.

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