Manual of Standards for Licensing/Rating of ATC Personnel

CIVIL AVIATION AUTHORITY OF NEPALL I C E N S I N G A N D RATING D I V I S I O NMEDICAL EXAMINATION FORM FOR ATCFull Name:.-.. Date of Birth: -Type of Licence: Initial / Renewal(EAR , NOSE & THROAT EXAMINATION & HEARING)Normal Describe abnormality in detail, use additionalYes No sheet if necessary & attach to this formNoseSinusesMouth and ThroatEars, general (int. & ext. canals)DrumsHearing Whispered Voice Conversational VoiceRight ear m ft 2m 6ftLeft ear m ft 2m 6ftAudiometry 500 1000 2000 3000Right ear dB loss [ ] [ ] [ ] [ ]Left ear dB loss [ ] [ ] [ ] [ ]Remarks, if any :Applicant is/is not medically fit for ... ....................... . licencePlace of examination ... ................................................ .Date... ..................................... . Aero-Medical Examiner's SignatureEyes, general, visual fieldsOphthalmoscopicPupils (equality and reaction)Ocular motilitynystagmus )( EYE EXAMINAITON, VISION & COLOR PERCEPTION)Normal Describe abnormality in detail, use additionalYes No sheet if necessary & attach to this form(associated parallel movement,Distant vision : Uncorrected CorrectedRight eye 6/ 6/Left eye 6/ 6/Both eye 6/ 6/Near vision :30 - 50 cm. ( 12- 20 in. ): N-chart value: 5Intermediate vision :100 cm. (40 in.) N-chart value:Color Vision : Normal ( ) Abnormal ( )Prescription for correcting lenses (when required) :Remarks if any :Applicant is/is not medically fit for ... ....................... . licencePlace of examination ... ................................................ .Date... ..................................... . Aero-Medical Examiner's Signature