Request for Pre-Placement Laser Eye Examination
(for Users of Class 3B and 4 lasers)

To communicate requests to have an eye examination, fill out and submit the form, below. After submitting the form, wait two days, and then call the Stanford University Occupational Health Center (SUOHC) (650-725-5308) to schedule an appointment.

Be sure to identify yourself as desiring a "Pre-placement Laser Eye Exam". Health Physics will have given SUOHC your name.

If you don't wish to have the examination please complete the STATEMENT DECLINING PRE-PLACEMENT EYE EXAM form to obtain the waiver form which should be printed out and sent by I.D. mail to Health Physics at ESF, 480 Oak Road, Mail Code 8007.

For assistance on laser safety questions call Arefeh Shanjani, 725-1411; e-mail: arefehs@.stanford.edu.
Or call the Health Physics office at: 723-3201.

Note: For the best visual effects please use an Internet Explorer browser.
In the Netscape browser some graphics are displayed differently, though the form will do the job intended.

Please use the TAB key only to move between the fields.

Name of person Requesting (First, Middle Initial, Last Name) Last 6 digits of your SSN
 XXX-
*Requester's e-mail Requester's Phone Number
Department or Division where you work with lasers Building and Room # where laser installation is located
Principal Investigator Name    


* The requester's e-mail is a required field.

Additional Information or Comments:

Use the following tips for the submission:

Please go over your information to ensure what you've entered is correct. When you're ready to submit your information, click on the Submit to EH&S button below. Please click on it only once to eliminate duplicates.

To clear all fields and start all over again, click on the Reset button below.

After you submit the request you will receive the confirmation of your order, the time and the date of your submission and all items you checked. You can print out this confirmation by using the Browser command on the tool bar: File->Print.


Back to Laser Program Home Page