Form PC-OMS-116 Prescription for Eyeglassess

Individual Specific Medical Evaluation Forms (15)

Eyeglass_Prescription_Measurement

Prescription for Eyeglassess

OMB: 0420-0550

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Shape1 Applicant Name

(Last, First, Middle Initial)

Date of Birth___________/_________ /___________

(Month/Day/Year)


Shape2


EYEGLASS PRESCRIPTION AND MEASUREMENT


Note to Applicant:


  • 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. 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.

  • 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.

  • If you must wear your contacts occasionally, please consider using single use, daily disposable lenses that do not require cleaning.



Instructions to health-care provider:

  • Please complete the attached Prescription for Eyeglasses form, to include frame measurements.

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





















Shape3

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 service 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 or failure to disclose relevant information may 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 U.S.C. 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, licensed clinical social worker 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 complete from to this address.

Peace Corps Eyeglass Prescription & Measurement PC‐OMS‐116 (Previous editions are obsolete) Page 1 of 2



Eyeglass Prescription & Measurement

  1. Frame measurements All blanks must be completed without exception

Eye Size

Bridge Size

Temple (Total Length)

Pupillary Distance


  1. Lens instructions Fill in all applicable information


Sph.

Cyl.

Axis

Prism

Base

Dec.






in

out

Dist.

R








L









N/A

Sph.

Seg. Height

Seg. Width

Seg. Inset

Total Inset and Dec.

Add for Reading

R

R

MM.

MM.

R

MM.

R

MM.

L

L

L

MM.

L

MM.



Sph.

Cyl.

Axis

Prism

Base

Dec.






in

out

Total Reading

R








L









  1. Type of lens Check one only

Bifocal Flat Top Executive Trifocal Single Vision

Note: The Peace Corps cannot replace progressive lenses or prescription sunglasses.

  1. Gross vision

    Uncorrected Corrected to____

    Right 20/_______

    Right 20/_______

    Left 20/_______

    Left 20/_______

    Binocular (both eyes) 20/_______

  2. Special instructions by prescriber

________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________


Signature of Prescriber _________________________________________________________ Date ______________

Title of Prescriber ______________________________________________ Phone _________________________

Address of Prescriber ______________________________________________________________________________

City ___________________________________ State ________________________________________________






Peace Corps Eyeglass Prescription & Measurement PC‐OMS‐116 (Previous editions are obsolete) Page 2 of 2

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorEckard, Elizabeth
File Modified0000-00-00
File Created2021-01-23

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