APPLICATION-PROFORMA-FOR-EYE-TEST

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					APPLICATION PROFORMA FOR EYE TEST FOR THE USE OF DISPLAY SCREEN EQUIPMENT (DSE) INFORMATION - to get a University of Leeds DSE eye test you need to: - complete the online DSE Training and Risk Assessment - https://complywise.net/cwleedsuni/ - fill in your details in the table below - ask your line manager or safety supervisor / coordinator to confirm that you are a user.

DETAILS OF USERS WORK In the table below provide details on the various work related visual tasks you are involved with, and the proportion of time you spend on these. Tasks Reading Other (specify) Near Distance % of Time Spent on Activity

Middle Distance DSE use Other (specify) Any Special Visual Requirement (beyond 6 metres) USER CONFIRMATION I can confirm that (Name) of School/Service is a DSE user on the basis that he/she uses DSE for one hour continuously* of for 1½ hours in total over the working day. I agree with the user details outlined in the table above. Signed _____________________________________ Date (Block letters) Send this completed form along with your DSE Risk Assessment to Health and Safety Services, Worsley Building for completion of the voucher section. It will then be returned to you.

VOUCHER

Number ___________

The above named person is entitled to have an eyesight test at Vision on campus. Individuals should arrange this directly with Vision 0113 245 5618 taking with them this form and your DSE assessment proforma. Lee Dewhurst Head of Health and Safety Services Date:

After the eye test Vision will issue you with a form indicating whether you need glasses etc. for near, middle or long distance. In addition the time interval for retesting will be given and this may differ from the standard 2 years. This Voucher is then valid for 3 Months only. Not valid unless signed by Head of Health and Safety Services or Faculty Health and Safety Manager.
* This also applies to part time workers

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