Record of Diver’s Vision Test Name: ID number: Contact Detail:

Result of Near Vision Test

Record of smallest text capable of being read by individual:

Corrected Uncorrected Left: Right:

Left: Right:

PASS / FAIL Pass criteria: Corrected or uncorrected near vision acuity permitting reading of N4.5 Times Roman at a minimum distance of 30cm in at least one eye, according to CSWIP-DIV-7-95-Part 1, paragraph 1.2. Acceptable alternative criteria are Jeager 1, Jeager 2 or Snellen 0.6

Approved eye examiner: Signed: Date of test:

Certificate not valid without stamp