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Get AWS Visual Acuity Record 2012

5 cm. All applicants shall take a color perception test. Eye examination results must be documented on this visual acuity form supplied by the AWS Certification Department. VISUAL ACUITY RECORD 8669 Blvd. FL 33166-6640 800 443-9353 or 305 443-9353 ext. 273 Last name Certification if applicable First name Member if applicable If scheduled to take an AWS certification exam site location Date TO APPLICANTS This form must be submitted for all Welding Inspector and Radiographic Interpreter applications. Applicants for the Certified Welding Educator are not required to complete this form* This completed eye examination form may be sent to the AWS Certification Department prior to the exam submitted on the day of the exam or sent to the AWS Certification Department after the exam* IMPORTANT This form must be completed and received in the AWS Certification Department not later than 30 days after the applicant s completed examination date. Applicants who have not fulfilled all requirements within 30 days after the examination date shall have all records scores and applications voided and may be in jeopardy of forfeiting application fees. Eye examinations shall be administered by an Ophthalmologist Optometrist Medical Doctor Registered Nurse or Certified Physician s Assistant or by other ophthalmic medical personnel and must include the state or province license number. Examinations shall be performed not more than 7 months prior to the date of the welding inspector examination or recertification* 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. No other forms will be accepted* AWS will not release exam results recertification results or renewals without a completed Visual Acuity Record on file. TO BE COMPLETED BY THE EYE EXAMINER 1. Please verify the customer s close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater 30. 5 cm please check 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 2. Through a color perception examination is the applicant colorblind Customer IS NOT colorblind C Customer IS colorblind* B 3. Examiner s Contact Information please print clearly Customer name Date of eye examination Examiner name Telephone number Examiner address City ST/Province Zip Country 4. Examiner professional status please check only one Ophthalmologist Examiner signature Visual Acuity Record Optometrist Medical Doctor Registered Nurse Certified Physician s Assistant State/Prov* License number August 27 2012. Applicants for the Certified Welding Educator are not required to complete this form* This completed eye examination form may be sent to the AWS Certification Department prior to the exam submitted on the day of the exam or sent to the AWS Certification Department after the exam* IMPORTANT This form must be completed and received in the AWS Certification Department not later than 30 days after the applicant s completed examination date. Applicants who have not fulfilled all requirements within 30 days after the examination date shall have all records scores and applications voided and may be in jeopardy of forfeiting application fees.

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