Facility Inspection & Certification

Kalimantan Operation

VISUAL ACUITY RECORD

NAME ____________________________________________________

A.

Near vision test (Jaeger 2 scale at 12 inches or equivalent)

_____ Passed

_____ Uncorrected

_____ Corrected

_____ Failed
B.

Far Vision test (Snellen scale at 20 feet or equivalent)

_____ Passed

_____ Uncorrected

20/40 minimum in at least one eye

Yes

_____ Corrected
No (circle one), If no, comment

_____ Failed
C.

Color Vision Test

_____ Passed
_____ Failed

D.

Limitations

_______________________________________________________
_______________________________________________________
_______________________________________________________

___________________________
Signature of Examiner

__________________________________
Signature of Examinee

__________________
Date

(TYPICAL)

13