Form PC-OMS-116 Prescription for Eyeglasses Form

Applicant Name ______________________________________________________________________________________________________________________

(Last, First, Middle Initial)

Date of Birth__________ /__________ /___________ Medical Case Number:________________________________________________

(Mo/Day/Year)

Eyeglass Prescription
& Measurement
OMB No.: 0420-0550
Expiration Date: 1/31/2014

Eyeglass prescription & measurement
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.

Privacy Act Notice
This information is collected under the authority of the Peace Corps Act, 22 U.S.C. 2501 et seq. It will be used primarily for the purpose of determining your eligibility
for Peace Corps service and, if you are invited to serve as a Peace Corps Volunteer, for the purpose of providing you with medical care during your Peace Corps
service. Your disclosure of this information is voluntary; however, your failure to provide this information will result in the rejection of your application to become
a Peace Corps Volunteer.
This information may be used for the purposes described in the Privacy Act, 5 USC 552a, including the routine uses listed in the Peace Corps’ System of Records.
Among other uses, this information may be used by those Peace Corps staff members who have a need for such information in the performance of their duties.
It may also be disclosed to the Office of Workers’ Compensation Programs in the Department of Labor in connection with claims under the Federal Employees’
Compensation Act and, when necessary, to a physician, psychiatrist, clinical psychologist or other medical personnel treating you or involved in your treatment
or care. A full list of routine uses for this information can be found on the Peace Corps website at http://multimedia.peacecorps.gov/multimedia/pdf/policies/
systemofrecords.pdf.

Burden Statement:
Public reporting burden for this collection of information is estimated to average 60 minutes per applicant and 15 minutes per physician per response. This estimate
includes the time for reviewing instructions and completing the collection of information. An agency may not conduct or sponsor, and a 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 estimate or any other aspect
of this collection of information, including suggestions for reducing this burden, to: FOIA Officer, Peace Corps, 1111 20th Street, NW, Washington, DC 20526 ATTN:
PRA (0420 - 0550). Do not return the completed form to this address.

Peace Corps · Eyeglass Prescription & Measurement

PC-OMS-116 (Revised 08/2011)

Page 1 of 3

Medical Case Number:

Prescription for Eyeglasses
Instructions: This form will be used to replace the Volunteer’s glasses should anything happen to them during service.
Please provide the following information.
The prescription will be filled stateside without the Peace Corps Volunteer being present.

1. Frame Measurements All blanks must be completed without exception
Eye Size

Bridge Size

Temple (Total) Length

Pupillary Distance

2 Lens Instructions Fill in all applicable information.
Sph.

Cyl.

Axis

Prism

Base

Dec.
in

out

R
Dist.
L
N/A

Sph.

Seg. Height

Add for R
Reading L

R

MM. MM. R MM.

R MM.

L

L MM.

L MM.

Sph.

Cyl.

Seg. Width

Axis

Seg. Inset

Prism

Total Inset and Dec.

Base

Dec.
in

out

Total R
Reading L

3. Type of Lens Check one only
h Bifocal h Flat Top h Executive h Trifocal h Single Vision Peace Corps cannot replace progressive lenses

4. Gross Vision
Uncorrected

Corrected to

Right 20/_________ Right 20/_________
Left 20/_________ Right 20/_________
Binocular (both eyes) 20/_________

5. Special Instructions by Prescriber
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________
Peace Corps · Eyeglass Prescription & Measurement

PC-OMS-116 (Revised 08/2011)

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Medical Case Number:

Signature of Prescriber___________________________________________________________________________________________________________________________Date___________________________
Title of Prescriber_______________________________________________________________________________________________Phone_______________________________________________________________
Address of Prescriber______________________________________________________________________________________________________________________________________________________________________________________________________________
City__________________________________________________________________________________State_____________________________________________________________________________________________________
To be completed by Peace Corps Staff
Account Number____________________________________________________________________Country__________________________________________________________________________________________
Style of Frame______________________________________Catalogue No.______________________________________Color__________________________________________________________________

Peace Corps · Eyeglass Prescription & Measurement

PC-OMS-116 (Revised 08/2011)

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