Notify Your Eye Doctor If You Plan to Wear Contact Lenses at Work

Instructions: Employees should bring this vision information form to their examining doctor to ensure he or she has all the data necessary to formulate the most precise prescription for all job activities.

If you require prescription safety glasses, PLEASE:

1. Complete the questions on this form

2. Bring the completed form to your eye doctor

3. Have your eye doctor sign this form.

4. Bring this form with your eyeglass prescription for your safety glass selection.

Describe the type of work you do with your eyes (e.g., machine operator, assembler, computer user).

Describe the size & type of printed materials you work with. (Bring an example with you to the doctor's office if you wish.)

How far away exactly do you work from your job responsibilities? (You can measure this distance by using a measuring tape from the bridge of your nose.)

Show your eye doctor what a comfortable distance for reading is best for you.

Describe the type of lighting in your work area.

Do you have any current difficulties with your current glasses? Current prescription?

Please describe the most hazardous activity in the course of your regular job responsibilities that could cause an eye injury

Are you requesting permission to wear contact lenses at your place of employment?  Y  N

Employee Name Date

Dr. Signature

Is the doctor recommending a change in your prescription?
Yes No

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