Form PC-OMS-116 Prescription for Eyeglassess

Applicant Name

(Last, First, Middle Initial)

Date of Birth___________/_________ /___________

(Month/Day/Year)

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.

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 20^th 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

2. 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

3. Type of lens Check one only

 Bifocal  Flat Top  Executive  Trifocal  Single Vision

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

4. Gross vision

   Uncorrected Corrected to____
   Right 20/_______	Right 20/_______
   Left 20/_______	Left 20/_______
   Binocular (both eyes) 20/_______

5. 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