VISION CERTIFICATE

GENERAL:
Initial examination is required, with or without corrective lenses, to prove:
1. Unaided or corrected near visual acuity in at least one eye shall be such that the candidate is capable of
reading N4 Time Roman type or Jaeger J1 at a distance of not less than 30 cm on a standard reading test
chart.
2. Far vision acuity of 20/40 or better and
3. Color perception test for red/green and blue/yellow differentiation
For re-certification, the examination is required to prove near visual acuity in at least one eye shall be such that the
candidate is capable of reading N4 Time Roman type or Jaeger J1 at a distance of not less than 30 cm on a standard
reading test chart.
This certification will be valid only if signed by one of the following:
Optometrist
Medical Doctor
Registered Nurse
ASNT/SNT-TC-1a Level III
ANSI N45.2.6 Level III

Certified Physicians Assistant

APPLICANTS INFORMATION :
Name:

Signature:

EXAMINERS INFORMATION:
Printed Name:
Profession:
Optometrist
Medical Doctor
ASNT/SNT-TC-1a Level III

Registered Nurse
ANSI N45.2.6 Level III

Certified Physicians Assistant

I, ______________________, certify that I have administered the vision examination (s) to the applicant
(Printed Name)
mentioned above.
Signature of Examiner and Date:
Professional License No.:
Address:
Telephone Number
Professional Stamp:

EXAMINATION RESULT (To be completed by Examiner)

Meets without Eye Correction
Far Vision 20/40 Minimum
Near Vision Jaeger J1 letters at 30 cm
Color Perception Pseudoisochromatic Plates
Red / Green Differentiation
Blue / Yellow Differentiation
Comments:

Meets with Eye Correction