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Visual Acuity Record

This document is a visual acuity record form for applicants taking AWS welding certification exams. It requires applicants to pass a near vision acuity test with Jaeger J2 letters at 12 inches or greater, with or without corrective lenses. The eye exam must be administered by a medical professional within 7 months of the exam date. The eye examiner must verify the applicant's close vision acuity and check for color blindness. The completed form is required to be submitted to AWS within 30 days of the exam for the applicant's results and certification to be released.

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505 views1 page

Visual Acuity Record

This document is a visual acuity record form for applicants taking AWS welding certification exams. It requires applicants to pass a near vision acuity test with Jaeger J2 letters at 12 inches or greater, with or without corrective lenses. The eye exam must be administered by a medical professional within 7 months of the exam date. The eye examiner must verify the applicant's close vision acuity and check for color blindness. The completed form is required to be submitted to AWS within 30 days of the exam for the applicant's results and certification to be released.

Uploaded by

neto-porto
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Visual Acuity Record October 11, 2012

VISUAL ACUITY RECORD




Last name Certification # (if applicable)
First name Member # (if applicable)
If scheduled to take an AWS certification exam, site location Date
TO APPLICANTS:
This form must be submitted for all Welding Inspector and Radiographic Interpreter applications. Applicants for the Certified Welding
Educator are not required to complete this form.

This completed eye examination form may be sent to the AWS Certification Department prior to the exam, submitted on the day of the
exam, or sent to the AWS Certification Department after the exam.

IMPORTANT: This form must be completed and received in the AWS Certification Department not later than 30 days after the applicants
completed examination date. Applicants who have not fulfilled all requirements within 30 days after the examination date shall have all
records, scores and applications voided and may be in jeopardy of forfeiting application fees.

Eye examinations shall be administered by an Ophthalmologist, Optometrist, Medical Doctor, Registered Nurse or Certified Physicians
Assistant or by other ophthalmic medical personnel, and must include the state or province license number. Examinations shall be
performed not more than 7 months prior to the date of the welding inspector examination or recertification.

All applicants must pass an eye examination, with or without corrective lenses, to prove near vision acuity on Jaeger J2 at 12 in. or greater
(30.5 cm). All applicants shall take a color perception test. Eye examination results must be documented on this visual acuity form supplied
by the AWS Certification Department. No other forms will be accepted.

AWS will not release exam results, recertification results, or renewals without a completed Visual Acuity Record on file.
TO BE COMPLETED BY THE EYE EXAMINER
1. Please verify the customers close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater(30.5 cm):
(please check one of the following for each eye)
AWS
Use
Only
OD

OS
Requires corrected vision to read Jaegar J2 at 12 in. or greater.

W
No correction is required to read Jaegar J2 at 12 in. or greater.

O
Unable to read Jaegar J2 at 12 in. or greater even with attempt at correction.

NQ

2. Through a color perception examination, is the applicant colorblind?
(please check one of the following for each eye)
AWS
Use
Only
OD

OS
Customer IS NOT colorblind

C
Customer IS colorblind.

B
3. Examiners Contact Information (please print clearly)
Customer name Date of eye examination
Examiner name Telephone number
Examiner address
City ST/Province Zip Country
4. Examiner professional status (please check only one)
Ophthalmologist Optometrist Medical Doctor Registered Nurse Certified Physicians Assistant

Examiner signature State/Prov. License number
8669 Doral Blvd. Suite 130 Doral, FL 33166-6640
(800) 443-9353 or (305) 443-9353, ext. 273

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