> INSTRUCTIONS

#### Purpose of the attached Form

The purpose of the attached two-part form is to provide BNL-OMC with
information necessary to determine that an individual to be cleared as a
laser user at BNL has met the medical requirements of ANSI Standard
Z136.1-2000 (Appendix E) governing the safe use of lasers.

This standard requires each Class 3B and 4 laser user to have a
preassignment eye examination by an ophthalmologist, which is recorded
on Part B of the attached form. Based upon medical history and type of
laser, a preassignment skin examination may also be required; it is
performed by a BNL-OMC physician.

#### Instructions to BNL Host/Supervisor

Please give this form, as soon as possible, to the prospective laser
user. It may be necessary to forward this file since the SBMS links are
generally not accessible off site.

#### Instructions to Laser User

As soon as possible:

1.  Contact one of the contracted local ophthalmologists from the list
    on the next page and request an appointment for a "laser eye exam
    for Brookhaven Lab." ([Note:]{.underline} You may also obtain this
    exam from a Board Certified Ophthalmologist other than those listed,
    but BNL cannot guarantee payment---consult with your BNL supervisor
    or host to discuss payment issues. Note also that no matter which
    ophthalmologist performs the exam, it must be recorded on Part B of
    the attached form---see step #4 below.)

2.  Complete Part A of the form. This provides BNL-OMC with needed
    contact and medical information.

3.  Give the completed form to your ophthalmologist, including this
    instruction page, the completed Part A, and the blank Part B.

4.  Your ophthalmologist should record his/her examination on Part B of
    the form and forward the form to BNL-OMC as instructed below.

5.  After receipt of the form, BNL-OMC will contact you if additional
    information or a skin examination is required.

#### Instructions to Laser User who wishes to submit a recent laser eye exam in lieu of having a new eye exam

A laser user who has already had a laser eye exam can submit this exam
to BNL-OMC in lieu of a new laser eye exam. BNL-OMC will then consider
whether the submitted exam is acceptable, or whether a new exam will
still be required. Generally, to be acceptable, the submitted exam must:

-   Be performed by a Board Certified ophthalmologist

-   Provide substantially the same information that is requested in Part
    B of the attached form

-   Have been performed within the last 3 years, with no laser eye
    accidents or changes in vision subsequent to the exam.

INSTRUCTIONS

The laser user who wishes to submit a recent laser eye exam for
consideration by BNL-OMC must do the following:

1.  Fill in Part A of the form.

2.  Fax Part A of the form to BNL-OMC at **631 344 7366**, along with
    the written record of the laser eye exam. (If unable to fax, mail as
    soon as possible to BNL-OMC at the address below).

3.  BNL-OMC will contact you if additional information or examinations
    are required.

#### 

#### Instructions to Ophthalmologist

1.  Please record your laser user eye examination on Part B of the
    attached form

2.  As soon as possible, please fax completed Parts A and B to BNL-OMC
    at **631 344 7366**. This is a secure, clinic fax that can receive
    confidential medical information. BNL-OMC's voice number for
    problems or questions is 631 344 3670.

3.  If you cannot fax the completed form, please mail it to:

> Occupational Medicine Clinic
>
> Brookhaven National Laboratory
>
> Bldg. 490
>
> Upton NY 11973-5000

Thank you.

#### Contracted Local Ophthalmologists

Dr. Charles Rothberg\
331 East Main\
Patchogue, NY 11772\
631 758-5300

The Ophthalmic Center\
Dr. Basilice\
3400 Nesconset Highway\
East Setauket, NY 11733\
631 751-2020

East End Eye Associates\
Dr. Sheren\
669 Whiskey Road\
Ridge, NY 11961\
631 744-8020

[Part A]{.underline}: Laser User Contact Information and Brief Medical
History---to be completed by laser user

Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_Life/Guest#\_\_\_\_\_\_\_\_\_\_\_\_\_\_Date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Usual/permanent
address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Usual/permanent phone
#\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
e-mail\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

BNL
Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
BNL extension\_\_\_\_\_\_\_\_\_\_\_

Name of BNL Supervisor, sponsor or
host\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
BNL extension\_\_\_\_\_\_\_\_\_\_\_

If at BNL on temporary basis: Expected arrival
date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_ Expected departure
date\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

What types of lasers will you be working with or near? \_\_\_\_UV
\_\_\_\_Visible \_\_\_\_\_IR \_\_\_\_Other (Specify)\_\_\_\_\_\_\_

## Brief Medical History

Please list current
medications\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Do you have either of the following conditions?

\_\_\_\_\_Aphakia (absence of a lens in one or both eyes)

\_\_\_\_Photosensitivity---unusual sensitivity of the skin or eyes to
sunlight or other light.

Please describe, if you checked either of the above:

Laser user
signature:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

[Instructions to laser user]{.underline}: After completing Part A, give
the entire form, including instructions, Part A and Part B, to the
examining ophthalmologist. [Exception]{.underline}: If you are
submitting a prior laser eye exam to BNL-OMC in lieu having a new exam,
submit this page (Part A) along with the record of that exam (see the
instruction page for details).

[Part B]{.underline}: To be Completed by Ophthalmologist

Examinee Name
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Date of Exam\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Current
Complaints:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Ocular History:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Pertinent Family
History:\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### Ocular Examination

## Visual Acuity

+------+----------+----------+----------+-------+----------+----------+
| ## F |          |          |          | ##    |          |          |
| ar P |          |          |          | Near  |          |          |
| oint |          |          |          | Point |          |          |
+------+----------+----------+----------+-------+----------+----------+
|      | Unc      | C        |          |       | Unc      | C        |
|      | orrected | orrected |          |       | orrected | orrected |
+------+----------+----------+----------+-------+----------+----------+
| OD   |          |          |          | OD    |          |          |
+------+----------+----------+----------+-------+----------+----------+
| OS   |          |          |          | OS    |          |          |
+------+----------+----------+----------+-------+----------+----------+

Refraction:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Macular Function (by Amsler grid or other
pattern):\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Visual Fields:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Color Vision:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Intraocular Pressure (if over age 40 or otherwise indicated):
OS\_\_\_\_\_\_\_\_ OD\_\_\_\_\_\_\_\_

Pupils & Motility:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Anterior Segment:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Fundus:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Impression:
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

### Examiner Information

Ophthalmologist Name & Title (printed):
\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Signature\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Medical License \# &
State\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Phone #\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

Office
Address\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_

-   Ophthalmologist: Forward completed Parts A & B to BNL-OMC, Bldg 490,
    Upton, NY 11973-5000.

-   Questions or problems call 631 344-3670.