8/12/2019 Eye Vision Test (1)
1/1
RECORD OF VISION TEST
Name of individual tested
:_____________________________________________________
Address
__________________________________________________________________
________________________________________________________________________
Telephone :_______________________ Email
:____________________________________Employer
:_________________________________________________________________
RESULT OF ISHIHARA COLOR VISION TEST
Record the Ishihara test result, and indicate if an alternative
(trade) test is suggested
Number Of Ishihara plates correctlyinterpreted:
Record of Ishihara plates failed (the test administrator
may,optionally, provide comment on the nature of color
perceptiondeficiency):
RESULT OF COLOUR VISION TRADE TEST
The employer should state the NDT methods and associated colors
used by employee:NDT METHOD ASSOCIATED
COLOURSCOLOURDIFFERENTIATION
CONTRASTDETECTION
RESULT OF NEAR VISION TEST
(Record the smallest text capable of being read).
CORRECTED UNCORRECTED
Times Roman N: ___________, or
Jaeger number : ____________
Times Roman N: _____________, or
Jaeger number : ____________
DETAILS OF PERSON CARRYING OUT AND RECORDING ANY OF THE ABOVE
TESTS
Signature: Name of tester:
Date of test:
Organization and telephone number (please use official stamp if
available):
NGUYEN PHUC LUAN
391/95, HUYNH TAN PHAT, TAN THUAN DONG, DISTRICT 7,HOCHI MINH
CITY, VIET NAM
+84 909.631.696 luann u en15091983 mail.com
