TWI CL Eye Test form Name ofindividual tested | Pyrex) Paoxy - a Date Of Birth Sle 12.19 FP | ‘Address Door xd -S0-63-4/2, SEETHA PETA, _RADENDRA 8G OR, VISHAKHA PAT 069 - 5300/4, | RESULT OF NEAR VISUAL ACUITY TEST Please record the smallest text capable of being read by the above named on a standard reading test | chart at a distance of no less than 30cm using Times Roman or Jaeger Text. Uncorrected Corrected (With the use of Glasses) QO re one pee ee | or Jaeger Point Size: J Times Roman Point Size:N. and record the results above right. Email address of tester: Date of Test: 213| ol Signature of Tester: Oat + doeehand (@ Quad to DETAILS OF PERSON PERFORMING THE ABOVE TEST: Print Name of Person who Performed the above ™ poaueo GET Emboss official stamp here - | CHETTY MS, 0.0. Or AVN pent ‘Note for tester: For this persons occupation he/she must be able to read Times Roman Point N45 or | Jaeger Point J1. Please record the results of the near vision eyesight test above left, but if he/she cannot meet this standard with eyes uncorrected please test the vision again using his/her glasses November 2014