A0001NCAH Occupational Vision Conservation Program - Prescription Safety Eyewear Authorization.docx
DOCX document 35 KB Posted
- Attached to
- SAFETY EYEWEAR
- Solicitation number
- 2020-SS25
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U.S. Department of Agriculture National Centers for Animal Health 1920 Dayton Avenue, Ames, IA 50010
NCAH Occupational Vision Conservation Program Prescription Safety Eyewear Authorization Form
I. EMPLOYEE INFORMATION
Name (Last, First, MI)
Program, Unit, Section
| Title, Series, Grade |
| Phone Number (Work) |
II. AUTHORIZED CONTRACT ITEM(S)
1. This form authorizes the individual listed above to obtain safety eyewear frames, prescription lenses, and/or accessories as needed from the following list:
| □ Frames (limited to frames priced ≤ $50.00 each) |
| □ Lenses, Single Vision Polycarbonate |
| □ Lenses, Flat Top 28 Polycarbonate, Bifocals |
| □ Lenses, Flat Top 28 Polycarbonate, Trifocals |
| □ Lenses, Flat Top 28 Polycarbonate, Progressive (No-Line Bifocals) |
| □ Lenses, Photochromic (Requires NCAH Pre-Authorization) |
| □ Coating, Anti-Reflective (Requires NCAH Pre-Authorization) |
| □ Side Shields, Detachable |
| □ Side Shields, Permanent |
| □ Respirator Inserts |
| □ Other (Specify):___________________________________________________________ |
2. All safety eyewear will meet or exceed the standards stated in the current revision of ANSI/ISEA Z87.1 “Occupational and Educational Personal Eye and Face Protection Devices”.
3. No more than two (2) units will be authorized to be dispensed every two (2) years, one (1) unit for far vision and one (1) unit for near vision, as needed. One (1) additional unit for the spectacle kit may be authorized for workers using full-face respirators. Additional prescription safety eyewear may be authorized by the NCAH Occupational Health Nurse or delegated authority to replace damaged units. The unit cost of the frames, lenses, and accessories will be based on current contract terms. This authorization is valid for one (1) calendar year from the date of signature.
III. AUTHORIZATION INFORMATION
NCAH Representative’s Signature
Date
NCAH Representative’s Printed Name
Phone Number (Work) image1.png
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