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