Form Dlab 2 PDF Details

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.

QuestionAnswer
Form NameForm Dlab 2
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesDLAB 2 CDL_Visual Examiniation Report_WEB wv dlab2 form

Form Preview Example

DLAB-2

 

 

 

 

 

 

 

 

STATE OF WEST VIRGINIA

 

 

 

 

 

 

 

 

 

 

CDL

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DEPARTMENT OF TRANSPORTATION

 

 

 

 

 

 

 

 

 

 

Rev. 3/09

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DIVISION OF MOTOR VEHICLES

 

 

Date

 

 

 

 

 

License No.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s full name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

State

 

 

 

 

 

 

 

Zip

 

 

 

 

 

Date of Birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

REPORT ON VISUAL EXAMINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Distant

 

 

Right

Left

 

 

Both

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST USED

 

Vision Only

 

 

Eye

Eye

 

 

Eyes

EVIDENCE OF SUPPRESSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Without

 

20

 

 

20

 

 

20

COORDINATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Glasses

 

 

 

 

 

 

 

 

 

@ 20 ft. EXO

 

 

 

ESO

 

 

 

RT. H.

 

 

 

 

LF. H.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

@ 20 ft. EXO

 

ESO

 

 

RT. H.

 

 

LF. H.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

With

20

20

 

20

FUSION-DISTANCE

 

 

 

 

 

 

 

 

 

 

 

TEST USED

 

Present

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

EXCELLENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Glasses

 

 

 

 

 

 

 

 

GOOD

POOR

 

NONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

With New 20

 

20

20

 

 

FUSION-NEAR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST USED

 

Prescription

 

 

 

 

 

 

 

 

EXCELLENT

GOOD

POOR

 

NONE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Possible Measure Above @ 20 Ft.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST USED

 

If Not, Please State Dist. Used.

 

 

 

EXCELLENT

GOOD

POOR

 

NONE

 

 

 

 

 

Fields - Horizontal Perception

 

 

 

COLOR VISION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TEST USED

 

Rt.o Lt.o

 

Total o

 

 

 

NORMAL

 

 

 

DEFICIENT

FAIL

 

 

 

 

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?

 

For near vision?

 

Is there any double vision?

 

 

 

If so, is it corrected with glasses or other treatment?

 

Any evidence of eye disease or injury?

If so, describe:

 

 

 

 

 

 

 

 

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?

 

If so, what restrictions?

 

 

 

Comments:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CERTIFICATION OF VISION SPECIALIST

I,

 

being licensed to practice in West Virginia, do certify that I have personally

 

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: