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U.A. LOCAL 501 PLUMBERS & PIPEFITTERS

VISUAL ACUITY FORM

FOR

WELDING INSPECTORS

The following exam shall be administered by a qualified Ophthalmologist or Optometrist.

The U.A. Local 501 NDE Level II visual Inspector is required to pass the following vision exams with or without correction.

1.) Near Vision Acuity

Capable of reading a Jaeger Number 2 at a minimum distance of 12 inches on a standard

 chart, or perception of an Ortho-Rater minimum of 8 or similar pattern.

 

Meets with correction ____________     Meets without correction _____________

 

2.) Color Contrast Differentiation

Successful completion of the Hardy-Rand-Rittler Color Blindness Examination.

(MAY BE SUBSTITUTED FOR MORE CURRENT TESTING METHOD)

 

Pass __________________      Fail __________________

 

I certify that I, ______________________________, administered an eye exam to

                                              (Examiner)

 

______________________________, on ___________________________, which

                  (Inspector)                                                     (Date)

 

demonstrated the vision capabilities above.

 

__________________________________

              Signature of Inspector

 

___________________________________     _________________________________

                Signature of Examiner                                                  Business

 

__________________________________     __________________________________

                          Address                                                       Phone/Fax Number