4140 REILLY RD

WICHITA FALLS, TX 76306

PHONE: 940.766.4545
FAX: 940.855.2833

VISION TEST

EMPLOYEE: ____________________________________________________AGE:___________

ADDRESS: _____________________________________________________

DISTANT VISION: RIGHT EYE: _________/__________

UNCORRECTED: LEFT EYE: _________/__________

CORRECTED: RIGHT EYE: _________/___________

LEFT EYE: __________/__________

NEAR VISION NOTE: JAEGER J1, OR EQUIVALENT, NOT LESS THAN 12” IN AT LEAST
ONE EYE, CORRECTED OR UNCORRECTED. PERSONNEL MUST HAVE VISION OF 20/25
MINIMUM IN AT LEAST ONE EYE CORRECTED OR UNCORRECTED TO MEET JAEGER J1
REQUIRMENT.

UNCRORRECTED: RIGHT EYE: _________/___________

LEFT EYE: _________/___________
CORRECTED RIGHT EYE: _________/__________
LEFT EYE: _________/___________

COLOR VISION NOTE: APPLICANT SHALL BE CAPABLE OF DISTINGUISHING AND

DIFFERENTIATING CONTRAST BETWEEN COLORS USED IN THE METHOD FOR WHICH
QUALIFIED AS DEMONSTRATED BY THE PRACTICLE EXAMINATION OR TEST
PERFORMANCE.

RESULTS: NORMAL: __________________ OTHER_______________

APPLICANT HAS SUCCESSFULLY PASSED EXAMINATION FOR:

DESTANT VISION: YES___________ NO___________

NEAR VISION: YES___________ NO___________
COLOR VISION: YES___________ NO___________

QUALIFIED EXAMINER: ______________________________ DATE__________________

EMPLOYEE SIGNATURE: ______________________________ DATE__________________

AUTHORIZED BY: ________________________________ DATE__________________