检查人员视力检查表InspectorVisionExaminationFormRev.0NDTXXX-姓名Name性别Gender近距离视力检查Near-VisionAcuityOnaStandardJaegerTestChat[Dist.:12inches(305)]左眼LeftEye右眼RightEye双眼BothEyes结果Result裸视力Natural□合格Acceptable□不合格Unacceptable矫正视力Corrected色觉检查ColorContrastDifferentiation1、按CIP(中国色盲检查图,第5版),能识别第1~5组。AccordingtoCIP(ChineseColorContrastDifferentiationChart,Version5th),theGroupfrom1to5canbediscerned..□合格Acceptable□不合格Unacceptable2、至少20个灰度等级能识别。Min.20CorrectReadingsRequired.□合格Acceptable□不合格Unacceptable评语Comments:检查日期ExaminationDate:下次检查日期DateofNextExamination:检查Examinedby日期Date