Dlab 2 is the latest addition to the D-series line of lab equipment from Shimadzu. It is a high-performance liquid chromatography system that offers superior performance and reliability. The system includes an online detector that provides real-time monitoring of analytical data, making it an ideal choice for process control and quality assurance applications. Additionally, the intuitive touch panel interface ensures easy operation, even for first-time users. To learn more about this exciting new product, be sure to read our latest blog post.
Question | Answer |
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Form Name | Form Dlab 2 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | DLAB 2 CDL_Visual Examiniation Report_WEB wv dlab2 form |
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STATE OF WEST VIRGINIA |
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CDL |
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DEPARTMENT OF TRANSPORTATION |
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Rev. 3/09 |
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DIVISION OF MOTOR VEHICLES |
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Date |
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License No. |
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Applicant’s full name: |
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Street Address |
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City |
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State |
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Zip |
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Date of Birth |
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REPORT ON VISUAL EXAMINATION |
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Distant |
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Right |
Left |
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Both |
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TEST USED |
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Vision Only |
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Eye |
Eye |
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Eyes |
EVIDENCE OF SUPPRESSION |
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Without |
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20 |
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20 |
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20 |
COORDINATION |
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Glasses |
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@ 20 ft. EXO |
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ESO |
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RT. H. |
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LF. H. |
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@ 20 ft. EXO |
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ESO |
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RT. H. |
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LF. H. |
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With |
20 |
20 |
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20 |
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TEST USED |
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Present |
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EXCELLENT |
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Glasses |
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GOOD |
POOR |
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NONE |
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With New 20 |
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20 |
20 |
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TEST USED |
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Prescription |
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EXCELLENT |
GOOD |
POOR |
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NONE |
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If Possible Measure Above @ 20 Ft. |
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TEST USED |
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If Not, Please State Dist. Used. |
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EXCELLENT |
GOOD |
POOR |
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NONE |
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Fields - Horizontal Perception |
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COLOR VISION |
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TEST USED |
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Rt.o Lt.o |
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Total o |
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NORMAL |
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DEFICIENT |
FAIL |
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To Examining Doctor:
Kindly complete this form. Please leave blank any spaces for test on which you have made no examination. If the case is peculiar, any ad- ditional comments on a separate sheet would be appreciated.
IMPORTANT: For proper identification, you will please the person whom you have examined sign the report in your presence.
Sign here:
Are corrective lenses needed for distant vision? |
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For near vision? |
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Is there any double vision? |
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If so, is it corrected with glasses or other treatment? |
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Any evidence of eye disease or injury? |
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If so, describe: |
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Can this be corrected or compensated for?
Any visual difficulty in seeing in dim light or at night?
Does applicant readily distinguish the colors of red, green and amber?
Does applicant have diabetic retinopathy?
Does applicant have bioptic lenses?
In your opinion, does this person have sufficient vision to operate a motor vehicle safely?
If yes, should there be any restrictions imposed? |
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If so, what restrictions? |
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Comments: |
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CERTIFICATION OF VISION SPECIALIST |
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I, |
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being licensed to practice in West Virginia, do certify that I have personally |
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examined the vision of the above named, that a true record of this examination appears on this report and that he or she signed this form in
my presence.
Signature of examining doctor:
Business address: |
Date: |
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