Who must complete the form?

The clinician or examiner who performed the vision screening should complete the clinical sections; HR or the designated administrator should confirm identity and file the completed form.

Can the form be signed electronically?

Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention are documented.

Do I need a Business Associate Agreement?

If the form contains protected health information and a vendor stores or processes it, execute a HIPAA Business Associate Agreement before transmitting or storing the record.

How should I store completed forms?

Store in a secure HRIS or document management system with role-based access, encryption at rest, and an audit trail; retain according to applicable federal and state retention rules.

What if results indicate impaired vision?

Document immediate restrictions, schedule a referral if required, and record the date for reassessment; communicate duties to supervisors while protecting privacy.

How often must I re-test employees?

Testing frequency depends on role risk and employer policy—common intervals are pre-employment and annually for safety-sensitive positions or sooner after incidents.

Electronic Signature
Templates
HR
HR Eyesight Test Form

HR Eyesight Test Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

HR EYESIGHT TEST FORM

Personal Information

Full Legal Name Employee ID Address

Phone:

Email:

Position Information

Job Title Department

Reporting Manager:

Start Date:

Salary / Rate

Employment History

Provide at least two recent employers. Include duties and reason for leaving.

Employer 1 - Company

Title:

Dates Employed:

Responsibilities Reason for Leaving Employer 2 - Company

Title:

Dates Employed:

Responsibilities Reason for Leaving

Education

Highest Degree Institution Graduation Date

References

Provide three professional references.

Reference 1

Phone:

Email:

Relationship Reference 2

Phone:

Email:

Relationship Reference 3

Phone:

Email:

Relationship

Legal Disclosures

At-Will Employment: Employment is at-will unless a written agreement signed by an authorized company representative states otherwise. Nothing in this form modifies or restricts the at-will relationship.

Equal Opportunity: The employer provides equal employment opportunity and will not discriminate on the basis of protected characteristics. Vision testing will be administered and applied consistent with applicable employment law and reasonable accommodation obligations.

Authorization and Certification

By signing below I certify that the information provided on this form is true and complete to the best of my knowledge. I authorize the employer and its designated medical personnel to perform vision screening and to obtain and review prior eye examination records necessary to evaluate my fitness for duty. I consent to disclosure of test results to Human Resources and any supervisor where such disclosure is job-related and consistent with business necessity.

I understand that failure to disclose relevant vision impairments or failure to comply with corrective lens requirements may affect my ability to perform assigned duties and may result in reassignment or restrictions. I authorize the release of vision-screening information to relevant safety personnel when required by job function.

Eyesight Examination (To Be Completed by Examiner)

Date of Exam:

Visual Acuity — Distance (without correction) OD: OS: OU:

Visual Acuity — Distance (with habitual correction) OD: OS: OU:

Visual Acuity — Near (with/without correction) OD: OS: OU:

Color Vision Screening administered: Yes No

Color Vision Result: Pass Fail

Peripheral Vision: Normal Impaired

Depth Perception: Normal Impaired

Pupil Reaction:

Corrective Lenses

Currently Worn: Yes No If yes, specify:

Examiner Notes

Results and Recommendations

Determination: Fit for duty without restriction Fit for duty with restrictions Not fit for duty

If restricted or not fit, provide specific limitations or recommended follow-up

Recommended Follow-Up Examination:

Examiner Name and Credentials Examiner Facility / Clinic

Confidentiality and Record Retention

Vision screening results are maintained as part of the employee's medical file and disclosed only to individuals with a legitimate business need or as required by law. The employer will retain examination records in accordance with company policy and applicable law.

Applicant Certification and Authorization

I certify that the information on this form is accurate and complete. I authorize the release of prior eye examination records and other relevant medical information to the employer for the purpose of assessing my fitness for work duties. I understand that this screening does not constitute a substitute for a comprehensive eye examination and that I may be referred to an eye care professional for further assessment if indicated.

Employee Name:

By:

Date:

What the HR Eyesight Test Form Is and when it’s used

The HR Eyesight Test Form documents a simple vision assessment used by employers to verify an employee’s visual acuity, color perception, and use of corrective lenses for job tasks. Typical uses include pre-employment screening for safety-sensitive roles, periodic workplace health checks, return-to-work evaluations after medical leave, and incident-driven assessments following accidents. The form records employee identifiers, test results, examiner details, recommendations (for corrective lenses or restrictions), and any follow-up actions. Proper completion creates a dated personnel record useful for compliance, risk mitigation, and accommodation decisions.

Why a clear HR Eyesight Test Form matters

A professional form reduces workplace risk, documents compliance with occupational health policies, and supports consistent fitness-for-duty decisions. It creates a reliable, auditable record for HR, safety officers, and medical reviewers while helping to justify reasonable accommodations or job restrictions when needed.

Who typically completes and relies on this form

HR, occupational health staff, and safety supervisors are the primary users; employees and designated examiners complete the test sections.

HR administrators responsible for personnel records and compliance tracking, coordinating testing, and filing outcomes.
Occupational health clinicians or contracted examiners who perform vision checks and record objective results and recommendations.
Safety managers and supervisors who review results to assign duties, safety accommodations, or restrictions.

Accurate completion ensures the form serves both medical-review and operational decision-making needs while protecting employee privacy.

Primary signers and reviewers

Occupational Health Nurse

Completes vision measurements, documents corrective lens requirements, and provides a clinical recommendation that HR and supervisors use to set work restrictions or accommodations.

HR Manager

Receives the completed form, files it in the employee record, coordinates any workplace adjustments, and ensures retention and privacy requirements are met.

Core sections to include on an HR Eyesight Test Form

A complete form groups personal data, test results, examiner details, recommendations, signature blocks, and a compliance log for versioning and follow-up.

Employee Details

Full legal name, employee ID, job title, department, and contact information. Accurate identifiers link the test to the correct personnel record and payroll files.

Test Date & Reason

Date of exam and reason (pre-employment, annual, incident, return-to-work). This anchors the record for retention and compliance timelines.

Visual Acuity

Near and distance acuity readings for each eye, with and without corrective lenses. Use standardized notation (e.g., 20/20, 20/40).

Color Perception

Document color vision screening result (pass/fail) and method used (Ishihara plates or equivalent), particularly for roles requiring color recognition.

Examiner Notes

Examiner name, credential, employer or clinic, and observations about functional limitations or need for referral to ophthalmology.

Outcome & Actions

Recommendation field for corrective lenses, duty restrictions, retest intervals, or referral. Also include space for employee comments and required follow-up dates.

Step-by-step: completing and filing the form

Follow these sequential steps to perform the test, capture results, and store the record correctly.

01

Prepare the form: Verify employee identity and pre-fill name, ID, and reason for test.
02

Conduct the test: Administer standardized visual acuity and color perception checks; record objective readings.
03

Record results: Enter measurements, examiner observations, and any immediate workplace restrictions.
04

Sign and file: Obtain required signatures, save to personnel file, and schedule any follow-up appointments.

Configuring a digital HR Eyesight Test workflow

Set up the e-form so it captures required data, enforces required fields, and routes results to the right reviewers automatically.

Setting	Configuration
Form Type	Fillable PDF with structured fields
Required Fields	Enforce name, date, examiner, and signature
Reviewer Routing	Auto-route to HR and safety manager
Authentication	Email or SMS code for signer verification

Technical considerations for eSubmission and integrations

Choose a platform that supports secure PDF, audit trails, and integrations with HR and document systems.

File formats: PDF and DOCX supported
Integrations: Connect to HRIS and cloud storage
Accessibility: WCAG 2.0 compatibility preferred

Ensure the platform can export signed records to your HRIS and retain tamper-evident audit logs for compliance and internal review.

Typical routing and filing flow for completed forms

A consistent routing procedure reduces delays and ensures records reach required reviewers and file locations.

Initiate: HR or supervisor requests the test and pre-populates the form.
Examine: Designated clinician performs test and completes fields.
Review: HR reviews outcomes and determines accommodations or restrictions.
Archive: Signed form saved in the employee’s secure personnel file.

Timing, frequency, and processing expectations

Set timing rules that reflect hiring cadence, regulatory needs, and job-specific risk profiles.

Pre-employment screening:

Conduct the test before first assignment to safety-sensitive tasks.

Periodic retesting:

Annual or role-specific intervals based on risk assessment.

Post-incident testing:

Test promptly after incidents affecting vision or safety.

Processing time:

Expect same-day capture and HR routing in typical digital workflows.

Follow-up deadlines:

Schedule referrals and retests within 14–30 days as indicated.

Common mistakes to avoid when preparing the form

Leaving examiner credentials blank, which undermines the clinical validity of the record and complicates employer reliance.
Using nonstandard acuity notation or omitting whether readings were with/without corrective lenses, causing ambiguous interpretation.
Failing to capture a dated signature from the examiner, which may render the form unusable for compliance or legal review.
Storing completed forms in unsecured locations or sending via unencrypted email, exposing protected health information.

Consequences of incomplete or incorrect forms

Workplace injury risk: Increased liability exposure

OSHA citations: Potential fines or enforcement

HIPAA breach: Regulatory penalties possible

Invalid records: Evidence may be inadmissible

Insurance cost increase: Higher workers’ comp premiums

Operational disruption: Delayed duty assignments

Two practical use scenarios for the HR Eyesight Test Form

These examples show how the form supports hiring and ongoing safety management in everyday HR operations.

Onboarding Vision Check

New hire screening completed during orientation using a digital form

Results flagged a need for corrective lenses
HR recorded the recommendation, the employee provided prescription documentation, and the worker was assigned non-safety tasks until corrected vision was verified.

Post-Incident Assessment

Employee reported vision concerns after a workplace incident

Examiner performed targeted acuity and color tests
The form documented temporary duty restrictions, scheduled an ophthalmology referral, and created a retraining timeline for supervisors.

Practical tips for accurate and efficient completion

Adopt these practices to improve data quality, reduce processing delays, and protect sensitive information.

Use standardized measurement units

Record acuity in 20/XX format and consistently note whether readings are with or without corrective lenses; standard notation reduces interpretation errors during clinical review.

Require examiner credentials

Capture the examiner’s license number or employer to support the validity of the exam and facilitate follow-up or audit requests by compliance teams.

Enforce required fields

In digital forms, make name, date, examiner, and signature mandatory to prevent incomplete records that cannot be relied on for accommodations or incident investigations.

Protect records and limit access

Store completed forms in secured personnel or health records systems, restrict access by role, and maintain an audit trail of who viewed or exported the file.

Comparing eSignature vendor capabilities and pricing for this form

A secure eSignature provider can simplify distribution, capture signatures, and maintain audit trails; compare starting price, trial availability, and key compliance features below.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (Business Premium+)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes (BAA required)	Yes (BAA required)	Yes (BAA required)	Varies	Varies
Envelope Cap	No cap	100 envelopes/user/year	Varies by plan	Varies by plan	Varies by plan

FAQs and troubleshooting for the HR Eyesight Test Form

Answers to common questions about completing, signing, and storing the HR Eyesight Test Form.

Need help? Contact support

Who must complete the form?
The clinician or examiner who performed the vision screening should complete the clinical sections; HR or the designated administrator should confirm identity and file the completed form.
Can the form be signed electronically?
Yes. Electronic signatures are valid under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention are documented.
Do I need a Business Associate Agreement?
If the form contains protected health information and a vendor stores or processes it, execute a HIPAA Business Associate Agreement before transmitting or storing the record.
How should I store completed forms?
Store in a secure HRIS or document management system with role-based access, encryption at rest, and an audit trail; retain according to applicable federal and state retention rules.
What if results indicate impaired vision?
Document immediate restrictions, schedule a referral if required, and record the date for reassessment; communicate duties to supervisors while protecting privacy.
How often must I re-test employees?
Testing frequency depends on role risk and employer policy—common intervals are pre-employment and annually for safety-sensitive positions or sooner after incidents.

be ready to get more

Join over 28 million airSlate SignNow users

Sign Now