DA Form 7595-4-5 "Perform Visual Acuity Testing"

What Is DA Form 7595-4-5?

This is a military form that was released by the U.S. Department of the Army (DA) on March 1, 2014. The form, often mistakenly referred to as the DD Form 7595-4-5, is a military form used by and within the U.S. Army. As of today, no separate instructions for the form are provided by the DA.

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PERFORM VISUAL ACUITY TESTING
For use of this form see TC 8-800; the proponent agency is TRADOC.
TABLES:
IV
STP 8-68W13-SM-TG, Task: 081-833-0193 Perform Visual Acuity
REFERENCES:
Testing
PRIVACY ACT STATEMENT
10 U.S.C. S 3013 Secretary of the Army; AR 350-1, Army Training Leadership and
AUTHORITY:
S
Development.
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT
certification IAW AR 40-68, AR 220-1 and AR 350-1.
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of
ROUTINE USES:
the Army's compilation of system of records notices may apply to this system.
DISCLOSURE:
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error
in processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
While working in a battalion aid station, your medical officer asks that you perform a visual acuity examination on a patient with a foreign body in his
eye. You must perform a visual acuity examination.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Identified the patient.
b. Explained the procedure to the patient.
c. Positioned the patient 20 feet away from the eye chart.
d. Instructed the patient to leave his corrective lenses on, if worn, except for reading glasses.
e. Covered one eye with an opaque card and instructed the patient to read the smallest line possible.
f. Repeated the procedure with the other eye.
g. Repeated the procedure with both eyes.
h. If in a field environment, determined gross visual acuity.
i. Recorded the results of the visual acuity examination.
4. Demonstrated Proficiency
Yes
No
5. Start Time
6. Stop Time
7. Initial Evaluator
8. Start Time
9. Stop Time
10. Retest Evaluator
12. Stop Time
13. Final Evaluator
11. Start Time
14. Evaluator's Comments
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc. (NREMT), skill sheets ©2011, this form has neither been prepared nor approved by NREMT.
Use is restricted to guidelines contained in the Preface to TC 8-800.
DA FORM 7595-4-5, MAR 2014
APD LC v1.00
PERFORM VISUAL ACUITY TESTING
For use of this form see TC 8-800; the proponent agency is TRADOC.
TABLES:
IV
STP 8-68W13-SM-TG, Task: 081-833-0193 Perform Visual Acuity
REFERENCES:
Testing
PRIVACY ACT STATEMENT
10 U.S.C. S 3013 Secretary of the Army; AR 350-1, Army Training Leadership and
AUTHORITY:
S
Development.
PRINCIPAL PURPOSE:
To ensure that accomplishment of training is properly credited to the correct individual for NREMT
certification IAW AR 40-68, AR 220-1 and AR 350-1.
Used by Unit personnel to monitor training. The DOD "Blanket Routine uses" set forth at the beginning of
ROUTINE USES:
the Army's compilation of system of records notices may apply to this system.
DISCLOSURE:
Voluntary. Failure to provide your name may result in a loss of credit for accomplishing the training or error
in processing applicable favorable personnel actions. For Official Use Only.
1. Soldier (Last Name, First Name, MI)
2. Date (YYYYMMDD)
SCENARIO:
While working in a battalion aid station, your medical officer asks that you perform a visual acuity examination on a patient with a foreign body in his
eye. You must perform a visual acuity examination.
GRADING SHEET
TASK
COMPLETED
1ST
2ND
3RD
3. Performance Measures
P
F
P
F
P
F
a. Identified the patient.
b. Explained the procedure to the patient.
c. Positioned the patient 20 feet away from the eye chart.
d. Instructed the patient to leave his corrective lenses on, if worn, except for reading glasses.
e. Covered one eye with an opaque card and instructed the patient to read the smallest line possible.
f. Repeated the procedure with the other eye.
g. Repeated the procedure with both eyes.
h. If in a field environment, determined gross visual acuity.
i. Recorded the results of the visual acuity examination.
4. Demonstrated Proficiency
Yes
No
5. Start Time
6. Stop Time
7. Initial Evaluator
8. Start Time
9. Stop Time
10. Retest Evaluator
12. Stop Time
13. Final Evaluator
11. Start Time
14. Evaluator's Comments
This form was prepared by U.S. Government employees for use in the 68W MOS. Although it contains, in part, copyrighted material from National
Registry of Emergency Medical Technicians, Inc. (NREMT), skill sheets ©2011, this form has neither been prepared nor approved by NREMT.
Use is restricted to guidelines contained in the Preface to TC 8-800.
DA FORM 7595-4-5, MAR 2014
APD LC v1.00