Prescription Safety Eye Wear Survey

Thank you for your interest in the Prescription Safety Eye Wear Program.


Please fill out the following questionnaire so we may learn more about your safety eye wear needs.


Please note: You will need to have a copy of your current eyeglass prescription (within the last two years). Interest in the program and completing this questionnaire does not guarantee you prescription safety eye wear.

 
 
 
 
 
 
 
 
 

What type of hazards would you encounter as part of your normal work function (i.e., impact, chemical, biological, etc.)? Please be specific.

 

Were you referred by the occupational health physicians to wear prescription eye wear as part of your medical accommodations? (Answer to this question does not affect your ability to obtain prescription safety glasses from EH&S)

 

When was your eye prescription last issued? (Prescriptions must be issued within the last 2 years)

 

Have you ever received Prescription Safety Eye Wear funded by EH&S?

 

Have you been fitted for personal protective equipment (PPE) by EH&S for your work? If the answer is no, please complete the Virtual PPE Fitting Form to request PPE.

 

When you were fitted for PPE, did you receive over the glasses eye wear to wear over your prescription eye glasses?

 

Were you given a face shield or was the use of a face shield recommended due to the fit of your safety glasses?