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    0455e - Welding Inspector Visual Acuity Record PDF

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    Abu Hanifa
    This document is a vision acuity record form for welding inspectors applying for or renewing their certification. It requires a medical professional to examine the applicant's vision and certify that the applicant meets the near vision requirements of reading Jaeger number 1 letters or equivalent at 30 cm, either corrected or uncorrected. The exam must have occurred within the last 12 months. The medical professional must fill out section 3 declaring the results of the exam and sign the form, which then needs to be attached to the applicant's certification application and sent to the CWB.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    0455e - Welding Inspector Visual Acuity Record PDF

    Uploaded by

    Abu Hanifa
    101 views1 page
    This document is a vision acuity record form for welding inspectors applying for or renewing their certification. It requires a medical professional to examine the applicant's vision and certify that the applicant meets the near vision requirements of reading Jaeger number 1 letters or equivalent at 30 cm, either corrected or uncorrected. The exam must have occurred within the last 12 months. The medical professional must fill out section 3 declaring the results of the exam and sign the form, which then needs to be attached to the applicant's certification application and sent to the CWB.

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    0455e_-_welding_inspector_visual_acuity_record.pdf

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    This document is a vision acuity record form for welding inspectors applying for or renewing their certification. It requires a medical professional to examine the applicant's vision and certify that the applicant meets the near vision requirements of reading Jaeger number 1 letters or equivalent at 30 cm, either corrected or uncorrected. The exam must have occurred within the last 12 months. The medical professional must fill out section 3 declaring the results of the exam and sign the form, which then needs to be attached to the applicant's certification application and sent to the CWB.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    101 views1 page

    0455e - Welding Inspector Visual Acuity Record PDF

    Uploaded by

    Abu Hanifa
    This document is a vision acuity record form for welding inspectors applying for or renewing their certification. It requires a medical professional to examine the applicant's vision and certify that the applicant meets the near vision requirements of reading Jaeger number 1 letters or equivalent at 30 cm, either corrected or uncorrected. The exam must have occurred within the last 12 months. The medical professional must fill out section 3 declaring the results of the exam and sign the form, which then needs to be attached to the applicant's certification application and sent to the CWB.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    CWB Form 455E/2017-1

    Welding Inspector Visual Acuity Record

    SECTION 1: IDENTIFICATION OF APPLICANT (Please print):

    Applicant's Name: Registration #:


    Application for Certification Renewal of Certification

    SECTION 2: VISION REQUIREMENTS:


    Evidence of satisfactory vision, as determined by a medical professional, must be provided by all new applicants
    and certified inspectors who are renewing their certification. The vision examination must have been performed no
    more than 12 months from the date of receipt of this form by the CWB.

    Near vision acuity shall permit reading a minimum of Jaeger number 1 or Times Roman N 4.5 or equivalent letters
    (having a height of 1.6 mm) at not less than 30 cm with one or both eyes, either corrected or uncorrected.

    Submission of a prescription for corrective lenses in lieu of this form is not acceptable.

    SECTION 3: DECLARATION OF EXAMINER:

    This is to certify that I, administered a test of visual acuity


    Examiner's Name (please print)
    to on
    Applicant's Name (please print) Examination Date (MM / DD / YYYY)

    I also certify that the applicant: (check applicable box)


    Meets the vision requirements in Section 2 without correction
    Meets the vision requirements in Section 2 with correction
    Does not meet the vision requirements in Section 2

    Check one of the following:


    Optometrist Ophthalmologist Medical Doctor
    Registered Nurse Other (Specify)

    Address:

    Signature of Examiner: Tel. #:

    FOR CWB USE ONLY:

    Reviewed by: Date:

    PLEASE ATTACH COMPLETED RECORD TO YOUR APPLICATION AND SEND TO THE CWB.
    RETAIN A COPY FOR YOUR FILE.

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