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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                                       Near Distance            % of Time Spent on Activity
 Reading
 Other (specify)

                                                          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                                                        Date:
        Head of Health and Safety Services

        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
    D:\Docstoc\Working\pdf\40e4a807-8664-4e15-9568-5396b56b783f.doc

				
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Description: APPLICATION PROFORMA FOR EYE TEST