Visual Impairment - Oregon 2026

1. Click ‘Get Form’ to open the Visual Impairment - Oregon document in the editor.
2. Begin by entering the worker’s name, date of injury (DOI), and WCD number in the designated fields at the top of the form.
3. For visual acuity, report central visual acuity for each eye. Fill in distance vision using Snellen notation and indicate if the worker can count fingers at four feet if distance vision is less than 20/400.
4. Next, provide near vision details using Snellen 14/14 notation or revised Jaeger type units. Specify if a natural lens or implanted prosthetic lens is present.
5. If applicable, measure visual field deficits using a Goldmann perimeter and report results on a perimetric chart or monocular Esterman grid.
6. Indicate any impairments of the lacrimal system by specifying affected eyes and whether conditions prevent regular work activities.
7. Report ocular motility issues, including binocular diplopia along standard meridians, and any additional ocular disturbances affecting either eye.
8. Finally, have the examining physician print their name, title, sign, and date the examination at the bottom of the form.

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