TWICL Eye Sight Test form Tanne of aiid ted [Ue Van Tore [Date oroieh [or Aug 2036 137 ‘ares Room Ni. 1206 A, An Binh ety, 232 Pham Van Bong, Bac Tu ern stra No, Viet Nam. ‘Tocomply with cetifeation requirements, ll CSWIP & BGAS-CSWIP Cetifeate holders are required to submit results of an eye test taken within the last 2 years. ‘AL CSW BGAS-CSWAP CERTIFICATE HOLDERS MUST TARE A NEAR VISION TEST: Isthe above named person capable ofreading Times Roman NAS or leger 1 on a standard reading test plate at a distance of no less han 0em unaided or coeected in at east one eye? ‘cawneaounconnecreo WY canrexowmriconrection [] isnoraste [] "AIBGRS-CSWIP & CSWIP NOT Cerificate Roles st avo provide the results ofa alour percption test. Colour perception shall be assessed bythe shhara 24 plate tat Colour ercepion est —satsterey UssatstetorrT] ‘adlographie Interpretation, Radiographic inspector & TOFD ceieate holders are also requled tocomplete a shades of Grey Perception Test ete fey Parapet saison] ealoe OTHE OEP PRONGTEORTET Dg 9 Date of Test: &/4 12019. ‘Print Name of Person who Performed the above ue [ee DANG THANK HUyEN somsee, LIE mos offlal stp here Profession peas tk Optometrist HONG NCOC HOSPITAL Medial Doctor {nfo hongngochosptal.s Registered Nurse ‘Aikes 35 Yen Nigh Sree. Certified to1S0 9712 Level C] HN Viet Neen Other (lease spec) C1 To (84) 361239 «Fa (3162988 Eyesight tests provded by optians/esptal et. willbe accepted as ong as they clearly state that al of the equrements nave been met, eee or for gudance please use ths TW CL Eye Test Form, Any observed icity during the eye test shoud be reported to te employer. Page Sof cswr/sye/2019