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VISIRON CERTIFICATE11

GENERAL
Initial examinati1onisgh fgr23equired, with or uwithout corrective lenses, to prove (1) near vision acuity of Snellen
English or equivalent Jaefg3egr J-14 at 2 inches; (2) far vision acuity of 20/40 or better and (3) color perception test for
red/green and blue1/yellfo4w d2ifferenti4altion.
For annlual re-certificationh, the examination is re2quired to prove near vision acuity or Snellen English or equivalent
Jaeger J-1 at 12 ignches.
This certificationf will be valid onl2yl if signed by one of the following:
Optometrist
Medical doctor
Registered nurse
Assistant
ASNT/SNT-TC-1a Level III
ANSI N45.2.6 Level III

Certified Physician's

APPLICANT INFORMATION (To be completed by Candidate)


Candidate
Name:

Date of
eye test

Candidate
Signature:

TEST/EXAMINATION RESULTS (To be completed by Doctor / Examiner)


Meets Without Eye Correction
(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

Meets With Eye Correction

Comments:

DOCTOR / EXAMINER INFORMATION (To be completed by Doctor / Examiner)


I administered the vision examination(s) to the applicant/candidate
The examiner's professional title is:
Optometrist
Certified Physician's Assistant

Name of the Docto r/ Examiner with stamp :

Signature of Doctor / Examiner:

Professional Address:
44545656

Medical Doctor
ASNT/SNT-TC-1a Level III

Registered Nurse
ANSI N45.2.6 Level III

Telephone Number:

State License Number: