| RECORD OF EYE EXAMINATION |
| [Prescribed under 49 of the West Bengal Factories Rules,1958] |
| Serial No. | Department/works | Name of Worker | Sex | Age | Occupation | Date of Employment | Date of Examination |
|---|---|---|---|---|---|---|---|
| 1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 |
| diff($to)->y;?> |
| Examination of Eye Sight | |||||||||||
|
9.Result
Visual Activity
Without Glass: R.E: 6/
Without Glass: L.E: 6/
With Glass: R.E: 6/
With Glass: L.E: 6/
|
10. Signature of Ophthalmologist | 11. Remarks | |||||||||
| Color Vision: | |||||||||||
| Refractive Power | Right eye | Left eye | |||||||||
| DSPH | DCYL | AXIS | VISION | DSPH | DCYL | AXIS | VISION | ||||
| Distance | |||||||||||
| Near reading | |||||||||||