visual impairment worker’s name:   doi:   wcd #:   note: all visual loss is measured with best correct


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 (2/20/DCBS/WCD/WEB)

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