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1 July 2012

Eyesight Test Certificate

Marine Safety Act 2010 (Vic), Marine Safety Regulations 2012 (Vic), National Standard for Commercial Vessels: Part D

Things to know before completing this form

You must have an eye test conducted by a suitably qualified optometrist, eye specialist or medical practitioner to ensure you meet the eyesight requirements to serve on a commercial vessel and hold a certificate of competency. You can use aids to vision (glasses, contact lenses etc) to achieve the required eyesight standards. Take your photo ID (drivers licence or passport) with you to the examination so the optometrist, eye specialist or medical practitioner can verify your identity. Persons with only one eye or poor vision in one eye (monocular vision) and/or colour blindness may be eligible for a certificate of competency. If you do not meet the eyesight requirements of the letter test and N5 chart test, you are ineligible to apply for or hold a certificate of competency and should not continue with your application. For further information contact Transport Safety Victoria (TSV) on 1800 223 022.

Your details (the applicant)

1. Surname Given names

2.

Date of birth (dd/mm/yyyy)

3.

Residential address Street number and name

Suburb

State

Postcode

4.

Postal address Same as above OR street number and name/PO box Suburb State Postcode

5.

Mobile number

Daytime telephone number Same as mobile OR ( ) Fax number (if applicable) ( )

Email

Telephone 1800 223 022 Fax 03655 6611 Email information@transportsafety.vic.gov.au

PO Box 2797 Melbourne VIC 3001 121 Exhibition Street, Melbourne VIC 3000
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Eyesight certification (to be completed by a qualified optometrist, eye specialist or medical practitioner)
Instructions for the optometrist, eye specialist or medical practitioner
Aids to vision are the only aid that may be used in a vision test. Persons with only one eye or poor vision in one eye (i.e. monocular vision) may be eligible for a Certificate of Competency. Colour vision testing is not required for an applicant for Marine Engine Driver Grade 2 or Marine Engine Driver Grade 3. All other applicants must undergo a colour vision test. You must sight photo proof of identification, verifying the person you are examining is the person named as the applicant.
Test Letter test (Snellen Principle)

Eyesight requirements

Does the applicant meet this requirement? Yes No

The applicant must have: without aids to vision Snellen Principle 6/60 (1.0 LogMar) in each eye with or without aids to vision Snellen Principle 6/6 (0.0 LogMar) in the better eye (except for engine crew where Snellen Principle 6/9 (0.2 LogMar) is acceptable); and Snellen Principle 6/9 (0.2 LogMar) in the other eye. Test results for applicant without aids to vision Right eye Left eye

Test results for applicant with aids to vision Were aids to vision required to achieve the required results? No Right eye Yes specify the test results with aids to vision below Left eye

N5 chart test Colour vision test

The applicant must be able to read N5 chart at 300500mm with or without aids to vision. Required for all applicants except Marine Engine Driver Grade 2 or Marine Engine Driver Grade 3. The ISHIHARA test shall be conducted using all 24 plates. To pass the test, a person must correctly identify at least 13 of the first 15 plates in the 24-plate version. The only aids to vision that may be used for colour vision testing are prescribed lenses worn by a person for the acuity test. Tinted glasses or contact lenses cannot be used. Colour correction devices shall not be worn for colour testing. Where an applicant fails the ISHIHARA colour vision test, they may be re-examined with the HOLMES-WRIGHT LANTERN TEST TYPE B. Test results: Number of colour plates correctly identified

Yes Yes

No No

Declaration and signature of optometrist, eye specialist or medical practitioner

I certify I have examined the applicant specified in this form. I have sighted photo proof of identification verifying the person I have examined is the applicant. I understand it is an offence under section 305 of the Marine Safety Act 2010 (Vic) to provide any false or misleading information and that penalties apply. Signature of optometrist/eye specialist/medical practitioner Date

X
Printed name Business address street number and name Provider number Daytime telephone number State Postcode

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Privacy: Transport Safety Victoria (TSV) collects and holds the personal information provided in this application to assist the Director, Transport Safety (Safety Director) to administer the Marine Safety Act 2010 (Vic) and Marine Safety Regulations 2012 (Vic). TSV is committed to protecting personal information in accordance with its obligations under the Marine Safety Act 2010(Vic). The personal information provided in this application may be disclosed to other government agencies in accordance with section 306 of the Marine Safety Act 2010(Vic) and section 177 of the Transport Integration Act 2010 (Vic). It is an offence under the Marine Safety Act 2010 (Vic) to give information that is false or misleading in order to obtain or attempt to obtain a certificate. The individuals whose personal information is collected on this application have a right to seek access to this personal information and to seek correction of any error in the personal information held. All individuals whose personal information is included with this application should be informed of this fact. For more information on privacy please refer to TSV's privacy statement at www.transportsafety.vic.gov.au/privacy.

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