Get AWS Visual Acuity Record 2018-2024

8669 NW 36 St 130 Miami FL 33166-6672 800 443-9353 extension 273 Email certification aws. org VISUAL ACUITY FORM Member Email address Date Last Name First Name MI Applicant This form must be submitted for all SCWI/CWI/CAWI/CRI/CWEng applications ONLY. IMPORTANT This completed Visual Acuity Form must be sent to the AWS Certification Department prior to the exam or no later than 60 days after the certification exam date for your CAWI/CWI/SCWI/ or 30 days for the rest of the programs requiring a Visual Acuity Form. Applicants who have not fulfilled all requirements after the certification exam date shall have test scores and application voided and may be in jeopardy of forfeiting application fees. AWS will not release exam results recertification results or renewals without a completed Visual Acuity Record on file. This form may be sent via fax email or mail* Eye Examination other ophthalmic medical personnel and must include the state or province license number. Examinations shall be performed within one 1 year of months for all other programs requiring a Visual Acuity Form* All applicants must pass an eye examination with or without corrective lenses to prove near vision acuity on Jaeger J2 at 12 in* or greater 30. 5 cm. Certification Department. No other forms will be accepted* 1. The following must be completed by the eye examiner A. Verify the customer s close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater 30. 5 cm Check ONLY one of the following for each eye OD AWS Use Only OS Requires corrected vision to read Jaegar J2 at 12 in* or greater. W No correction is required to read Jaegar J2 at 12 in* or greater. O Unable to read Jaegar J2 at 12 in* or greater even with attempt at correction* NQ B. Through a color perception examination is the applicant colorblind Customer IS NOT colorblind C Customer IS colorblind* B 3. Examiner s Contact Information print clearly Customer Name Date of eye exam Examiner Name Phone Number Examiner Address City State Zip/Postal Code Country 4. Examiner professional status check only one Ophthalmologist Examiner Signature Visual Acuity Form1224 Optometrist Medical Doctor Registered Nurse Certified Physician s Assistant State/Prov* License number April 18 2018. This form may be sent via fax email or mail* Eye Examination other ophthalmic medical personnel and must include the state or province license number. Examinations shall be performed within one 1 year of months for all other programs requiring a Visual Acuity Form* All applicants must pass an eye examination with or without corrective lenses to prove near vision acuity on Jaeger J2 at 12 in* or greater 30. Examinations shall be performed within one 1 year of months for all other programs requiring a Visual Acuity Form* All applicants must pass an eye examination with or without corrective lenses to prove near vision acuity on Jaeger J2 at 12 in* or greater 30. 5 cm. Certification Department. No other forms will be accepted* 1. The following must be completed by the eye examiner A. .