Fill and Sign the Visual Impairment Oregon Form

Visual Impairment Worker’s name:       DOI:       WCD #:       Note: All visual loss is measured with best correction, using the lenses recommended by the worker’s physician. Visual acuity: Report the central visual acuity for each eye, distance and near vision. L.E. R.E.Distance vision, reported in standard increments of Snellen notation     /         /     If distance vision is less than 20/400, can the worker count fingers at four feet? yes no yes no Near vision, reported in Snellen 14/14 notation. Revised Jaeger or American point type units             Natural lens yes no yes no Implanted prosthetic lens yes no yes no Aphakia yes no yes no Visual field deficits: N/A Measure each visual field using a Goldmann perimeter with a lll / 4e stimulus. Report the results on either: 1. a perimetric chart which indicates the extent of retained vision out to 90 degrees for each of the eight standard 45-degree meridians, as reproduced above, or 2. a monocular Esterman grid Ocular motility: N/A Report binocular diplopia in degrees along the eight standard meridians, as reproduced above. Impairments of lacrimal system: N/A If too little or too much tearing restricts the worker from any part of regular work, specify the affected eye and whether the condition: Additional ocular disturbances N/A Indicate the affected eye:       Mild Moderate Severe is a nuisance but does not prevent most regular work activities Glare (photophobia) Monocular diplopia prevents some regular work-related activities Stereopsis prevents most regular work-related activities Examining physician name and title (print or type):       Signature: Date of examination:       440-2312 (5/13/DCBS/WCD/WEB)