Form PC-OMS-116 Prescriptin Eyeglassess Form

OMB Control No. 0420-xxxx
Expiration Date xx/xx/xxxx

Peace Corps
COVER PAGE: Eyeglass Form

The Peace Corps Office of Medical Services strongly discourages Volunteers from wearing
contact lenses while serving overseas, unless there is a medical reason documented by an
ophthalmologist. Contact lenses, including extended wear soft contacts, are associated with a
variety of eye infections and other inflammatory problems. One of the most serious problems is
infectious keratitis, which can lead to severe cornea damage and could result in permanent
blindness requiring a corneal transplantation. The risk of permanent eye damage is heightened in
the Peace Corps environment where there is limited access to sterile water or proper storage
conditions for cleaning solutions. In addition, when bacterial eye infections occur, immediate
assessment and treatment by an ophthalmologist is not possible. If you must wear your contacts
occasionally, please consider using single use, daily disposable lenses that do not require
cleaning.

Burden Statement:
Public reporting for this collection is estimated to be 120 minutes per applicant. this estimate includes the time for reviewing the
instructions and completing the collection of information. An agency may not conduct or sponsor, and person is not required to respond
to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden, to: FOIA
Officer, Peace Corps, 1111 20th Street, NW, Washington, DC 20526 Attn: PRA (0420-xxxx). Do not return the completed for to this address.

Peace
Corps

Name (Print)

2

The prescription will be filled stateside without the Peace Corps
Volunteer being present.
ALL BLANKS MUST BE COMPLETED WITHOUT EXCEPTION

Bridge Size

LENS INSTRUCTIONS

/

Instructions: This form will be used to replace the Volunteer's
glasses should anything happen to them during service.
Please provide the following information.

FRAME MEASUREMENTS

Eye Size

/

Social Security Number

Prescription for
Eyeglasses
1

Date

Temple (Total) Length

Pupillary Distance

FILL IN ALL APPLICABLE INFORMATION

Sph.

Cyl.

Axis

Prism

Sph.

Seg. Height

Seg. Width

Seg. Inset

Base

In

Dec.

Out

R
Dist.
L

N/A
R
Add
for
Reading L

MM.

3

Sph.

MM.

Cyl.

Axis

MM.

R

MM.

L

Prism

MM.

Base

Dec.

R

L

Type of Lens
Bifocal
Trifocal

Flat Top

(Check one only)

4

Executive

Single Vision

GROSS VISION
Uncorrected

Corrected to

Right 20/______

Right 20/______

Left 20/______

Left 20/______

Binocular (both eyes) 20/______

Peace Corps cannot replace progressive lenses

5

R

L

N/A
Total
Reading

MM.

Total Inset and Dec.

Special Instructions by Prescriber

Signature of Prescriber

Date

Title of Prescriber

Phone

Address of Prescriber

City

State

TO BE COMPLETED BY PEACE CORPS STAFF
Account Number
Style of Frame

Country

Catalogue No.

Color

Privacy Act Notice: Authority to request this information is the Peace Corps Act 22 U.S.C.§ 2501 et seq. This information will be used to fill eyeglass prescriptions, and is maintained in the
Volunteer’s Peace Corps medical file. This information may be used for the routine uses described in the Privacy Act, 5 USC 552a, and in the Federal Register at 65 Fed. Reg. 53,722 (September 5, 2000) and 50 Fed. Reg. 1950, 1962 (January 14, 1985) regarding Peace Corps system of records PC-17 (Volunteer records). Disclosure is voluntary, but failure to provide the information
will prevent the prescription from being filled.
PC-OMS-116 (Rev. 09/2009)

Previous Editions are Obsolete