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QA Consulting Limited

Visual Acuity Form

As required in Procedure 1.1 Procedure for the Qualification and Certification of NDT Personnel, the individual named
below has been given an examination to assure natural or corrected near distance acuity in at least one eye. The individual
has a near distance acuity of 20/25 (Snellen) at 16" (42 cm) +/- 1" (2.54 cm) in at least one eye, natural or corrected. The
ability to perceive an Ortho-Rater minimum of 8 or similar test pattern is also acceptable.

The individual has demonstrated the ability of distinguishing and differentiating contrast among colors or shades of gray used
in the methods for which certified.

NAME Number

Acceptable Not Acceptable

Near Vision

Color Vision

Gray Scale

Corrective Lenses Required? Yes No

Comments:

Examined by: Name & Title:

DATE:

Level 3 Accepted:

Date:

Form 1.2.1, Rev. 0, November 7, 2013

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