Stanford University Laser Safety Manual

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Appendix A - Preplacement laser eye examination procedures at Palo Alto Clinic
Appendix A1 - Statement declining preplacement laser eye examination
Appendix D - Laser safety measures for high powered (class 3 and 4) lasers
Back Cover - Simplified Method for Selecting Laser Eye Protection for Intrabeam Viewing

I, _____________________________ have been told of the University policy regarding the
           (NAME PRINTED)
opportunity for personnel who work in areas where Class 3 or 4 lasers are operating to have eye examinations prior to working in the areas. I understand that the eye examination would provide a baseline for comparison in the event of possible injury and that it might reveal evidence of earlier injuries or of eye conditions which might make it more hazardous to work with lasers. Nonetheless, I decline to have the examination.

Note: It is possible that failure to have an exam could prejudice a person's ability to recover damages, if a pre-existing condition that contributed to and injury was determined to exist.

Signed:                                                                               

Dated:                                                                                 

Department:                                                                         

Principal Investigator:                                                             

(Project to retain copy on file)

(rev 10/92)