ࡱ> RjQ qbjbj 88j1gj1gP V V 844hD0,h0j0j0j0j0j0j0$35000Rh0h0-~/`HM(Z.T0000n.m6|m6(~/~/Zm6/|00}0m6V X :  Display Screen Equipment and Eyesight Tests Sections to be filled in by: Section A Staff member Section B - Optician Section A Staff member application Name: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Staff number: Date: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I write to apply for an eye sight test under the Health and Safety (Display Screen Equipment) Regulations 1992 as amended by the Health and Safety (Miscellaneous Amendments) Regulations 2002 I understand that the ý will reimburse the full cost of the eyesight test. Signed: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -  Section B To the Optician Please examine, advise and, if necessary, prescribe and dispense for the above named person in accordance with the requirements of the Health and Safety (Display Screen Equipment) Regulations 1992 as amended by the Health and Safety (Miscellaneous Amendments) Regulations 2002. Please indicate if glasses are required specifically for DSE Opticians name: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - In confidence to Mr/Mrs/Miss/Ms: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - I examined you on and advised you that you (please tick): - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Need corrective lenses specifically for DSE workDo not need corrective lenses specifically for DSE work Description of DSE lenses requirement (if applicable)  Opticians signature: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Date: - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Opticians stamp: If an ordinary prescription is suitable for DSE work, you will be unable to claim the cost of your glasses. If this eye examination shows that a pair of glasses are needed specifically for DSE work the ý will: Contribute up to 30 towards the cost of the lenses Contribute up to 30 towards the cost of the frames Note for ý Staff: Reclaiming Your Expenses The comment boxes must be filled in by the optician detailing what is specifically required for DSE work. This form must be signed, dated and stamped by the Optician. Once all information has been obtained with necessary signatures etc, go to Concur for reimbursement and attach this form to your claim - Failure to do any of the above could result in non-payment of your ý Expenses claim -     Updated Feb 2022 /0MNgqt|}~ ' ( ) D I J ƹuuudddddduuuudddduu h'^hRjCJOJQJ^JaJh'^hRjOJQJ^J#h'^hRj5CJOJQJ^JaJhKCOJQJ^JhjOJQJ^J hKChKCCJOJQJ^JaJhKChKCOJQJ^JhKC*hRhKC5CJ EHOJQJ\^JaJ hKC5CJhRhKC5CJjhRhKC5CJU"/0MNg}~( ) J I $IfgdB$If^`gd'^ $IfgdRj^gdj & FgdKCgdKCgdKC   I e f c 678<>±±¢c辱5Cϴj5Cϴ#󰭰5Cϴ<5CJOJQJ^JaJhEg5CJOJQJ^JaJ h'^hRjCJOJQJ^JaJh'^hRjOJQJ^Jh'^hjOJQJ^Jh'^hOJQJ^JhBOJQJ^JhBhBOJQJ^J" 78>d____gdKCnkd-$$Ifl&~& t064q4 lap yt'^ $Ifgdj $If`gd'^ $IfgdRj $If^gd'^ Z_*+,;<HHH Hⷷ⭟⁁؁؟؁؁؁ح؟hfhfOJQJ^J hfhfCJOJQJ^JaJhfCJOJQJ^JaJhKCOJQJ^JhjOJQJ^JhBOJQJ^JhBhBOJQJ^JhfOJQJ^JhKChKCOJQJ^J heohfCJOJQJ^JaJ2+,< $IfgdKCgdKCgdB123456789:;<DEPST'˻ykkkkZ hhhhCJOJQJ^JaJhhCJOJQJ^JaJhKCOJQJ^JhhOJQJ^Jh<OJQJ^JhpiOJQJ^JhKChKCOJQJ^Jh'^hpiOJQJ^Jh'^hpi5OJQJ\^J heohhCJ(OJQJ^JaJ(h'^hhOJQJ^Jh'^hfOJQJ^JhfOJQJ^J#xoo $IfgdKCkd$$Ifl0%7# t064q4 lapyt'^234567xsjjjjjj $IfgdKCgdKCkd$$Ifl0%7# t064q4 lapyt'^789:;<T>?QvqqqqqqqqqqlgdRjgdKCkdn$$Ifl0&-Q t0644 lapyt< ''=>?'()5<]dt鶶|||ooh'^heOJQJ^J#h'^he5CJOJQJ^JaJh-sOJQJ^JhpiOJQJ^JheoOJQJ^JheOJQJ^JhRjOJQJ^J hhhhCJOJQJ^JaJhhCJOJQJ^JaJhKCOJQJ^JhhOJQJ^JhKChKCOJQJ^J+QRST()].kN $Ifgdf $If^gd'^ & F$Ifgd'^ $Ifgdegdf & Fgd-sgdRj,.8KfkKNOPQRSTUVWXYZ[\lmnopqɼh{2Yh<h<h<OJQJ^Jh}Hjh}HU heheCJOJQJ^JaJh'^hpiOJQJ^Jh'^heOJQJ^J-NOPRSUVXY[\mnopqgd<nkd $$Ifl&~& t064q4 lap yt'^61h/R :ppi. 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