Vision/Color Screening Note (Occupational Medicine)

Date/Time: [encounter date and time]

Location: [clinic or site name]

Examiner: [name and credentials]

Ordering Entity: [employer, agency, or program name]

Authorization Type: [employer request / regulatory requirement / post-offer screening / other]

Worker Name: [full name]

DOB: [date of birth]

ID/MRN: [identifier]

Job Title: [job title]

Safety-Sensitive Position: [Yes / No]

Primary Visual Demands: [brief description of job-related visual tasks]

Reason for Screening: [pre-placement / periodic surveillance / return-to-duty / regulatory credentialing / task-specific qualification / other]

Authorization and Disclosure

• Identity Verification: [method used]
• Consent to Perform Screening: [obtained / declined] (If declined, document disposition.)
• Authorization to Release Results: [obtained / not obtained] (Disclosure limited to pass/fail determination, need for corrective lenses, work restrictions, and follow-up requirements. Diagnoses and detailed medical history are not disclosed unless separately authorized.)
• Employer-Facing Report Generated: [Yes / No]
• Worker Received Copy: [Yes / No]

Relevant History

• Corrective Lens Use: [none / glasses / contacts / both]; [lenses brought to exam / lenses not brought]
• Pertinent Ocular History: [eye surgery / major trauma / known eye disease / none relevant] (Include only history relevant to the applicable standard.)
• Acute Symptoms: [none / vision loss / eye pain / diplopia / new floaters or flashes / other] (If present, note onset and laterality.)
• Color Vision History: [known deficiency / prior occupational test failures / none reported]

(If history was not obtained per protocol, state "History not obtained; screening-only protocol.")

Test Conditions

• Corrective Lens Condition During Testing: [uncorrected / with glasses / with contacts / both conditions tested]
• Testing Distances: Distance acuity at [distance]; Near acuity at [distance] (if performed)
• Lighting Conditions for Color Testing: [description of illumination]
• Instruments/Materials Used:
  • Distance/Near Acuity: [instrument name]
  • Color Vision: [test name and plate count/version]
  • Visual Fields: [confrontation / instrument / formal perimetry] (Include device/model if instrumented.)
  • Depth Perception: [test name]

Objective Results

(Include only test sections that were performed. If a test was required but not completed, document "Not performed" with the reason.)

Visual Acuity

(Record Snellen-equivalent values; do not use "normal" or "WNL." If an eye has no usable vision, record "no vision.")

Distance Acuity (Corrected): OD [value], OS [value], OU [value]

Distance Acuity (Uncorrected): OD [value], OS [value], OU [value]

Near Acuity (Corrected): OD [value], OS [value], OU [value] (Include only if tested.)

Near Acuity (Uncorrected): OD [value], OS [value], OU [value] (Include only if tested.)

[Additional acuity notes] (Include pinhole testing, test repetitions, or reliability concerns if applicable.)

Color Vision

(Include when job requires color recognition.)

• Test Used: [exact test name and plate count/version]
• Result: [pass / fail]; [score]
• Confirmatory Testing: [performed / not indicated / not available] (If performed, document method and result.)
• Color-Sensing Lenses: [prohibited and confirmed not used / suspected use / not assessed]

Visual Fields

(Include when required by the standard or for navigation/vehicle operation duties. Record degrees per eye when quantification is required; do not use "normal" or "full" when quantified values are required.)

• Method: [confrontation / instrument / formal perimetry]; [device/model if applicable]
• Result: OD [degrees or description], OS [degrees or description]
• Documentation: [values recorded above / perimetry report attached]

Depth Perception

(Include when required by the applicable standard.)

• Test Used: [exact test name]
• Result: [pass / fail]; [stereoacuity value with units if measured]

Applicable Standard and Determination

Standard: [name and version of regulatory or employer standard] (If no standard was provided, state "No standard provided; pass/fail determination cannot be made.")

Requirements vs Results

(Include only domains required by the applicable standard.)

• Distance Acuity: Requirement: [threshold]; Result: [measured values]; [Meets requirement / Does not meet requirement]
• Near Acuity: Requirement: [threshold]; Result: [measured values]; [Meets requirement / Does not meet requirement]
• Color Vision: Requirement: [threshold]; Result: [measured values]; [Meets requirement / Does not meet requirement]
• Visual Fields: Requirement: [quantified degrees]; Result: [measured degrees]; [Meets requirement / Does not meet requirement]
• Depth Perception: Requirement: [threshold]; Result: [measured value]; [Meets requirement / Does not meet requirement]

Determination: [Meets standard—no restrictions / Meets standard—with restrictions / Does not meet standard—not cleared / Indeterminate—standard not provided or testing incomplete]

Rationale: [brief statement citing specific domains and measured values driving the determination]

Plan

(Include this section only when findings are abnormal, indeterminate, or result in restrictions. Omit entirely if worker meets the standard without restrictions.)

• Immediate Re-test Criteria: [criteria such as lenses forgotten, suboptimal lighting, test reliability concerns]
• Referral Recommendation: [specialty, urgency, and purpose of evaluation]
• Work Guidance/Restrictions: [temporary restrictions pending evaluation or corrective measures]
• Worker Counseling: [results reviewed with worker / understanding confirmed]
• Acute Symptom Disposition: [urgent evaluation instructions] (Include only if acute symptoms present.)

Signature

Examiner Signature: [electronic signature with credentials and date/time]

Performed by: [name, role, credentials, date/time] (Include only if technician performed testing and clinician interpreted results.)

Reviewed/Authorized by: [clinician name, credentials, date/time] (Include only if different from examiner.)