UPDATED 2/8/2012
SECTION1: EMPLOYEE INFORMATION
EMPLOYEE NAME: EMPLOYEE NUMBER:
JOB CLASSIFICATION: BARGAINING UNIT:
AGENCY/DEPARTMENT:
ADDRESS:
PHONE: EMAIL:
AI 2901
Supervisor:_____________________, I here by certify that the named employee above is
exposed to more than 18.75 hours per work week and has obtained a prescription from
their personal eye specialist/doctor at their own expense or through their City paid
Vision Benefit. Supervisors Signature:_______________________________________
BRIEFLY DESCRIBE YOUR VDT USE PATTERNS:
HAVE YOU ATTENDED THE REQUIRED ERGONOMICS TRAINING COURSE
HOW MANY HOURS PER DAY DO YOU OPERATE A VDT?
HAS YOUR PERSONAL EYE DOCTOR PRESCRIBED VDT GLASSES? (PLEASE ATTACH
COPY OF PRESCRIPTION TO THIS FORM.)
SECTION 3 :AUTHORIZATION TO RECEIVE BENEFIT
(To be completed by Risk Management)
Prescription Attached Bargaining Unit Eligible Exposure Criteria Met
Approved Not Approved (state reason: )
The above cited employee is hereby authorized/not authorized to participate in the City's VDT Glasses Program
and is eligible to receive one pair of VDT glasses. (Strike non-applicable language)
Risk Management, Authorizing Signature
Date
INSTRUCTIONS
1. Employee completes section 1 and 2 above.
2. Attach copy of prescription form from personal eye doctor recommending the use of VDT glasses
3. Mail or fax completed form and prescription to:
150 Frank H. Ogawa Plaza, Suite 2352
Oakland, CA 94612
(510)238-7971/(510)238-4749(Fax)
CITY OF OAKLAND
VDT GLASSES AUTHORIZATION REQUEST FORM (AI 2901)
City of Oakland,
Risk Management Division
click to sign
signature
click to edit
![]()
