You are on page 1of 1

RECORD OF VISION TEST

Name of individual tested:_____________________________________________________



Address__________________________________________________________________
________________________________________________________________________
Telephone:_______________________ Email:____________________________________

Employer:_________________________________________________________________

RESULT OF ISHIHARA COLOR VISION TEST
Record the Ishihara test result, and indicate if an alternative (trade) test is suggested
Number Of Ishihara plates correctly
interpreted:
Record of Ishihara plates failed (the test administrator may,
optionally, provide comment on the nature of color perception
deficiency):




RESULT OF COLOUR VISION TRADE TEST
The employer should state the NDT methods and associated colors used by employee:
NDT METHOD ASSOCIATED
COLOURS
COLOUR
DIFFERENTIATION
CONTRAST
DETECTION




RESULT OF NEAR VISION TEST
(Record the smallest text capable of being read).
CORRECTED UNCORRECTED

Times Roman N: ___________, or

Jaeger number : ____________


Times Roman N: _____________, or

Jaeger number : ____________
DETAILS OF PERSON CARRYING OUT AND RECORDING ANY OF THE ABOVE TESTS
Signature: Name of tester:


Date of test:


Organization and telephone number (please use official stamp if available):







NGUYEN PHUC LUAN
391/95, HUYNH TAN PHAT, TAN THUAN DONG, DISTRICT 7,
HOCHI MINH CITY, VIET NAM
+84 909.631.696 luannguyen15091983@gmail.com