Police service recruitment - Could You?

For official use only
Candidate number

EYESIGHT FORM

All applicants are required to have their eyesight tested. This may be done by the force as part of the medical assessment or you may be asked to take this form to an optometrist (optician). You are not required to submit an eyesight report with your application form. You will be notified by the force if this is needed.

Name of patient	Date of birth


Address

	Postcode

	Right Eye	Left Eye	Binocular
Unaided Vision	6/	6/	6/
Aided Vision	6/	6/	6/
Near Vision tested at 40cm's			N/
Is the field of vision full by confrontation test?			Y/N

Normal Y/N	Monochromat Y/N
Specify test used:

Has the patient undergone refractive surgery?		Y/N
If yes, state type of surgery eg LASIK, PRK, LASEK
Date of Surgery	Right Eye	Left Eye
Details of any side effects post surgery

Optometrist's name

Optician's stamp

Address

Postcode

Optometrist's signature	Date
Applicant's signature (in the presence of the optician)

You may have seen a chart like the diagram below at your opticians. The actual chart is much longer and is read from a distance of 6 metres. Each line equates to a standard.

DEFG

HIJKLM

NOPQRSTU

VWXYZABCD

EFGHIJKLMNOPQ

RSTUVWXYZABCDEF

6 / 60

6 / 36

6 / 24

6 / 18

6 / 12

6 / 9

6 / 6

6 / 5

6/12	or better with either your right or left eye
6/6	with both eyes together

If you wear spectacles or contact lenses you also need to reach 6/36 without your spectacles or lenses

N6 at 40cm with both eyes together (aided)

The use of colour correcting lenses are not acceptable.

Severe colour vision deficiencies (monochromats) are not acceptable. Anomalous trichromats are acceptable. Severe anomalous trichromats or dichromats are also acceptable but you will need to be aware of the deficiency and make appropriate adjustments.

Radial Keratotomy, Arcuate Keratotomy or corneal grafts are not acceptable.

Other forms of refractive surgery such as LASIK, LASEK, PRK, ICRS, epiflap are all acceptable provided that six [weeks] have elapsed since surgery, there are no residual side effects and the other eyesight standards are met.