Oregon > Workers Comp > Medical

Visual Impairment 2312 - Oregon

Visual Impairment Form. This is a Oregon form and can be used in Medical Workers Comp .
 Fillable pdf Last Modified 10/1/2014
Get this form for FREE as a print-only pdf

Visual Impairment Worker's name: DOI: WCD #: Note: All visual loss is measured with best correction, using the lenses recommended by the worker's physician. Visual acuity: Report the central visual acuity for each eye, distance and near vision. Distance vision, reported in standard increments of Snellen notation If distance vision is less than 20/400, can the worker count fingers at four feet? Near vision, reported in Snellen 14/14 notation. Revised Jaeger or American point type units Natural lens Implanted prosthetic lens Aphakia L.E. / yes no yes yes yes no no no R.E. / yes no yes yes yes no no no Visual field deficits: N/A Measure each visual field using a Goldmann perimeter with a lll / 4e stimulus. Report the results on either: 1. a perimetric chart which indicates the extent of retained vision out to 90 degrees for each of the eight standard 45-degree meridians, as reproduced above, or 2. a monocular Esterman grid Impairments of lacrimal system: N/A If too little or too much tearing restricts the worker from any part of regular work, specify the affected eye and whether the condition: is a nuisance but does not prevent most regular work activities prevents some regular work-related activities prevents most regular work-related activities Examining physician name and title (print or type): Signature: 440-2312 (5/13/DCBS/WCD/WEB) Ocular motility: N/A Report binocular diplopia in degrees along the eight standard meridians, as reproduced above. Additional ocular disturbances N/A Indicate the affected eye: Mild Moderate Glare (photophobia) Monocular diplopia Stereopsis Severe Date of examination: American LegalNet, Inc. www.FormsWorkFlow.com
Link/Embed this Document

Popular Searches

  1. amendment to complaint
  2. information subpoena
  3. stipulation of discontinuance
  4. Petition for Administration
  5. deposition subpoena
  6. Request for entry of default
  7. bill of costs
  8. durable power of attorney
  9. Form Interrogatories-General
  10. Preliminary Change of Ownership Report

Bookmark and Share