Da Form 7655 – Fill Out and Use This PDF

The DA 7655 form, officially titled as the Department of the Army Armed Forces Eye and Vision Readiness Summary, serves a crucial role for Army personnel. It is designed to assess an individual’s visual health and refractive status to ensure their fitness for duty in scenarios where regular access to eye care might not be available. This assessment includes not only an initial examination but also allows for the capture of spectacle prescription and eye history data, making it an essential step for soldiers in maintaining operational readiness. To ensure your readiness, complete the form by clicking the button below.

Get Form Now Download PDF

Da Form 7655 PDF Details

Ensuring the visual readiness and health of Army personnel is a critical aspect of maintaining operational efficiency and overall troop readiness. The Department of the Army takes this responsibility seriously, as evidenced by the requisites outlined in the DA Form 7655, known as the Armed Forces Eye and Vision Readiness Summary. This document serves as a testament to the Army's commitment to its service members' ocular health, detailing the necessity for periodic assessments by qualified eye care professionals. With specific instructions on how to carry out these assessments, including the measurement of visual acuity, a review of the soldier's ocular history, and a comprehensive examination to determine fitness for duty, the form embodies a pivotal link between individual health care and military preparedness. Further emphasizing the importance of these evaluations, the form outlines the procedures for those who have undergone recent exams, thereby avoiding redundancy while ensuring the most up-to-date vision information is available. Through its structured approach to gathering essential visual health data, ranging from spectacle prescriptions to a determination of any conditions that may impede a soldier's ability to serve, especially in remote environments, the DA 7655 encapsulates a blend of procedural efficiency and a focused concern for the well-being of Army personnel. The form is not just about collecting data; it's about ensuring that soldiers are physically ready to face the challenges of their duties, regardless of where they are deployed.

Question	Answer
Form Name	Da Form 7655
Form Length	1 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	15 sec
Other names	a7655 fjso form 7566 april 2010

Form Preview Example

DEPARTMENT OF THE ARMY

ARMED FORCES EYE AND VISION READINESS SUMMARY

For use of this form, see DA Pam 40-506; the proponent agency is OTSG.

PRINCIPLE PURPOSE (S): Army personnel are required to have a periodic assessment of visual health and refractive status by an optometrist or ophthalmologist to determine fitness for prolonged duty without ready access to eye and vision care. If the Soldier has had an eye examination within the past 24 months, this form may be completed by the eye care provider to capture the spectacle prescription and eye history data without having to repeat the examination. Measurement of visual acuity is an annual requirement and may be conducted by the unit or in conjunction with the Periodic Health Assessment.

ROUTINE USE (S): Periodic Health Assessment and Vision Readiness Classification.

DISCLOSURE: Voluntary; however, failure to provide the information may result in delays in assessing refractive and vision health needs for military service. Information on this form may also be used to determine Vision Readiness Classification.

1.SERVICE MEMBER'S NAME (Last, First, Middle Initial)

2. DATE OF BIRTH

3. BRANCH OF SERVICE

4. UNIT OF ASSIGNMENT

5. UNIT ADDRESS

EXAMINATION RESULTS:

To the Doctor: The individual that you are examining is an Active Duty/National Guard/Reserve member of the United States Armed Forces. We request your assessment of his/her eye and vision health for potential worldwide duty. Please complete the following information, using visual acuity determination, ocular history review, biomicroscopy and refraction as a suggested minimum clinical examination. This form is meant to determine fitness for prolonged duty without ready access to eye and vision care and is not intended to address the member’s comprehensive ophthalmologic or optometric needs.

6. DATE OF VISION SCREENING (YYYYMMDD):		DATE OF SPECTACLE RX (YYYYMMDD):

(1) UNCORRECTED DISTANCE VISUAL ACUITY		(2) BEST CORRECTED DISTANCE VISUAL ACUITY
Right Eye	20/	Right Eye	20/
Left Eye	20/	Left Eye	20/
Both Eyes	20/	Both Eyes	20/

(3) IF > 45, UNCORRECTED NEAR VISUAL ACUITY

(4) IF > 45, BEST CORRECTED NEAR VISUAL ACUITY

Both Eyes

20/

Both Eyes

20/

(5) SPECTACLE PRESCRIPTION (MINUS CYLINDER FORMAT, IF NEAR VISION ONLY ANNOTATE IN BIFOCAL FORM):

Right Eye

SPHERE

CYLINDER -

AXIS

ADDITION +

PRISM

Left Eye

SPHERE

CYLINDER -

AXIS

ADDITION +

PRISM

(6)

PUPILLARY DISTANCE:

FAR

NEAR

(7)

Does the patient have any ocular condition(s) that may present problems in austere environments far removed from routine medical care?

YES

If yes, please state condition(s):

(8)

Will the patient require a 180-day supply of medication(s) to treat an ophthalmologic condition(s)?

YES

If yes, please provide medication(s) and dosage(s):

(9)

Has the patient undergone a refractive surgical procedure(s) in the past?

YES

If yes, please provide month, year and type of procedure(s):

7. DOCTOR'S PRINTED NAME

8. STATE LICENSE NUMBER

9. DOCTOR'S ADDRESS & TELEPHONE OR E-MAIL ADDRESS

10. DOCTOR'S SIGNATURE

DA FORM 7655, JUN 2009

APD LC v1.00

How to Edit Da Form 7655 Online for Free

When using the online PDF editor by FormsPal, it is possible to fill out or edit Da Form 7655 right here and now. To keep our editor on the cutting edge of practicality, we aim to put into practice user-driven features and enhancements regularly. We're routinely happy to receive suggestions - play a pivotal part in remolding the way you work with PDF docs. Getting underway is easy! All that you should do is stick to the following easy steps down below:

Step 1: Access the PDF in our tool by pressing the "Get Form Button" at the top of this page.

Step 2: When you access the online editor, you will get the form all set to be filled out. Besides filling in different blanks, you can also do other actions with the form, that is adding your own textual content, changing the original textual content, inserting illustrations or photos, putting your signature on the PDF, and a lot more.

If you want to finalize this document, make sure that you provide the required information in every single blank:

1. Firstly, when filling in the Da Form 7655, beging with the page with the next fields:

2. Right after finishing the previous section, go on to the subsequent step and enter the essential particulars in all these blank fields - Right Eye, SPHERE, Left Eye, SPHERE, CYLINDER, CYLINDER, AXIS, AXIS, ADDITION, ADDITION, PRISM, PRISM, PUPILLARY DISTANCE, FAR, and NEAR.

It's simple to make a mistake when filling out the FAR, and so you'll want to take another look prior to when you send it in.

Step 3: Spell-check the information you have inserted in the blanks and then press the "Done" button. Join us today and instantly get access to Da Form 7655, prepared for downloading. Each change made is handily saved , helping you to customize the file at a later time as required. FormsPal offers protected form tools without personal data record-keeping or distributing. Rest assured that your information is safe with us!

Da Form 7655 – Fill Out and Use This PDF

Da Form 7655 PDF Details

Form Preview Example

How to Edit Da Form 7655 Online for Free

Da Form 7655 isn’t the one you’re looking for?

Related Documents