Northumberland, Tyne and Wear NHS Foundation Trust Application for an Eye Test and/or special corrective lenses Part of HS-PGN-05 – Display Screen Equipment – (NTW(O)20 Health and Safety Policy)

APPLICATION FOR AN EYE TEST AND OR SPECIAL CORRECTIVE LENSES

The Display Screen Equipment Regulations 1992 state that the employer must bear the cost of special corrective lenses to a person described as a user of display screen equipment on a regular basis.

The Trust’s obligation is to provide the basic cost of a standard, single vision lens. Claims for varifocals and bifocal lenses will not be considered. It’s recommended that most people should get their eyes tested every two years; however circumstances may require this to be done more frequently.

Name Staff ID

Job Title

Email Address

Department

Base & Address

Date of Request

An eye care voucher will be provided which allows the user a full eye examination and a basic pair of single vision spectacles if the user wishes an upgrade can be made at the user’s expense.

Statement from Manager

I confirm that the above claimant’s work involves the use of display screen equipment and is described as a User under those regulations and the guidance contained within PGN O5.

Manager Name:

Manager Signature (Initials) Tick for Approval

Patient Safety Office Use only: Voucher No:

Issued & Sent on:

Signed (Tick)