OQ RPI & Plastics

HSSE - Occupational Health

Safety Glasses Prescription Form
CALL-OFF ORDER RELEASE
To : Yateem Optician Branch : Date: ……/……./…… (dd/mm/yyyy)
( Abdulla Ali Yateem & Partner Co ) Tel:
Please supply the below-mentioned item(s) in accordance with the Terms and Conditions of the
Contract with OQ to the following employee.
Employee Name : ……………………………………............ Staff No……………………… Contact No…………………….
Function…………………………………………..Department……………………………………..Location………………………..
GL Account………………………………………… Cost centre ………………………………
The service requested: ( tick the selected service)
 Unifocal (single vision) lenses as per eye test report with sturdy polycarbonate frame.
 Unifocal (single vision) lenses as per eye test report.
 Varifocals (progressive lenses) lenses as per eye test report with sturdy polycarbonate frame.
 Varifocal (progressive lenses) lenses as per eye test report.
 Sturdy polycarbonate frame only (including fixing charges of existing lens).

Name:…………………………….Staff No…………… Name :…………………………………Staff No:………………

(Print Name of Line Manager) (Print Name of OQ clinic Doctor)

Signature: Signature: Stamp :

Date : ……./….../..…… (dd/mm/yyyy) Date: ..…./….. /……… (dd/mm/yyyy)
Procedure to Use this Form :
• Employee to fill the form with department GL account and cost center.
• Line Manager to approve & sign the form.
• Present the form to OQ RPI & Plastics clinic to verify the need for the prescription glasses & keep
a copy for future reference in employee medical file.
• Present the original form & OQ ID card to the above-mentioned supplier.
• Supplier to check the visual acuity of the employee & select the suitable Lens from the approved
list as per the contract. (Supplier to keep the original form).
• Sign the form when collecting the glasses from the supplier & retain a copy.
• Email the copy of the signed form to RPI & Plastics OH team. (saif.almoqbali@oq.com)
• Supplier will process the invoice directly with OQ RPI & Plastics.

To be filled and stamped by the Vendor/Acknowledged by the Employee. The above-mentioned

items have been delivered and received by the employee.

Signature of the Employee:…………………….. Date of receipt ……/……/……… (dd/mm/yyyy).

OQ RPI & Plastics OH