Aws Visual Acuity Form PDF Details

Have you ever wondered what the world looks like to someone who is visually impaired? The Amazon web services team has created a tool that can give you a glimpse into what life is like for those who suffer from low vision or blindness. Called the Aws Visual Acuity Form, this online resource offers a simple way for individuals to measure their visual acuity and see how it compares to others. The form uses a standardized eye chart that measures visual clarity in both eyes. Results are then graphed and compared with avg. values from the general population. For anyone interested in learning more about sight impairment, or simply curious about how they compare to others, the Aws Visual Acuity Form provides an easy way to do so.

Form NameAws Visual Acuity Form
Form Length1 pages
Fillable fields0
Avg. time to fill out15 sec
Other namesjaeger eye exam form, visual acuity form, cwi eye exam, visual acuity test form

Form Preview Example

8669 NW 36 St, #130 Miami, FL 33166-6672

(800)443-9353 extension 273 Email


MEMBER #: _______________ EMAIL ADDRESS: ______________________________________ DATE: _________________

LAST NAME: __________________________________ FIRST NAME: ______________________________ MI: ___________


This form must be submitted for all SCWI/CWI/CAWI/CRI/CWEng applications ONLY.

AWS will not release exam results, recertification results, or renewals without a completed Visual Acuity Record on file.

IMPORTANT: This completed Visual Acuity Form must be sent to the AWS Certification Department prior to the exam, or no later than 60 days after the certification exam date for your CAWI/CWI/SCWI/ or 30 days for the rest of the programs requiring a Visual Acuity Form. Applicants who have not fulfilled all requirements after the certification exam date shall have test scores and application voided, and may be in jeopardy of forfeiting application fees. This form may be sent via fax, email, or mail.

Eye Examination

Eye examinations shall be administered by an Ophthalmologist, Optometrist, Medical Doctor, Registered Nurse or Certified Physician’s Assistant or by other ophthalmic medical personnel, and must include the state or province license number. Examinations shall be performed within one (1) year of the certification examination date, or within one (1) year of the certification expiration date for renewal or recertification of CWI/SCWI and seven (7)

months for all other programs requiring a Visual Acuity Form.

All applicants must pass an eye examination, with or without corrective lenses, to prove near vision acuity on Jaeger J2 at 12 in. or greater (≥30.5 cm). All applicants shall take a color perception test. Eye examination results must be documented on this Visual Acuity Record form supplied by the AWS Certification Department. No other forms will be accepted.

1.The following must be completed by the eye examiner:

A. Verify the customer’s close vision acuity to Jaeger J2 specifications at a distance of 12 inches or greater(≥30.5 cm)

(Check ONLY one of the following for each eye)



Requires corrected vision to read Jaegar J2 at 12 in. or greater.

No correction is required to read Jaegar J2 at 12 in. or greater.

Unable to read Jaegar J2 at 12 in. or greater even with attempt at correction.

B. Through a color perception examination, is the applicant colorblind?

(Check ONLY one of the following for each eye)



Customer IS NOT colorblind

Customer IS colorblind.

3. Examiner’s Contact Information (print clearly)










Customer Name:


Date of eye exam:








Examiner Name:


Phone Number:


Examiner Address:













4. Examiner professional status (check only one)



Zip/Postal Code:





Medical Doctor

Registered Nurse

Certified Physician’s Assistant

Examiner Signature:

State/Prov. License number:





Visual Acuity Form_1224


April 18, 2018

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cwi visual acuity form completion process shown (stage 1)

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