SSN (9 Digits, No Spaces Nor Dashes)

Corneal Refractive Surgery Aeromedical Summary

A waiver request for corneal refractive surgery requires completion of this form. Submit a copy of this form along with the operative report(s) and member’s current physical exam to NAMI Code 342. You may fax documents to (850) 452-3883 or send an email with scanned attachments to . LBFS may only issue a 90 day temporary up-chit upon the signatures of two flight surgeons and an eye care provider. Member must also meet all criteria for waiver as specified in Chapter 12.15, Corneal Refractive Surgery, U.S. Navy Aeromedical Reference and Waiver Guide.

Date

SSN

Name (First Middle Last)

Rank/Rate/Title O-10O-9O-8O-70-6O-5O-4O-3O-2O-1WO-5WO-4WO-3WO-2WO-1E9E8E7E6E5E4E3E2E1N/A Service USNUSNR (Active)USNR (Sel Res)USNR-TARUSMCUSMCRDoN Employee/contractor Age

Aviation duty Designated naval aviatorNaval flight officerNaval aeromedical officerNaval aircrewmemberProject specialistParachute jumperAerospace physiology technicianAir traffic controllerUAV operatorStudent Naval AviatorStudent Naval Flight Officer

Total flying hours Flying hours last six months

Primary aircraft type flown Not applicableStrike/fighterMaritimeRotary wingTilt rotor

Command name UIC

Aviation examination facility name UIC

Aeromedical point of contact e-mail Point of contact phone DSNCommercial

OUODOS Date of surgery Type of surgery PRK (including LASEK)LASIK

OUODOS Name of surgical facility

N/AOS Date of surgery Type of surgery N/APRK (including LASEK)LASIK

N/AOS Name of surgical facility

ODOS Pre-operative cycloplegic refraction plano-+ sphere-0.25 x-0.50 x-0.75 x-1.00 x-1.25 x-1.50 x-1.75 x-2.00 x-2.25 x-2.50 x-2.75 x-3.00 x-3.25 x-3.50 x SE-+

OSNot applicable Pre-operative cycloplegic refraction plano-+ sphere-0.25 x-0.50 x-0.75 x-1.00 x-1.25 x-1.50 x-1.75 x-2.00 x-2.25 x-2.50 x-2.75 x-3.00 x-3.25 x-3.50 x SE-+

Date ODOS Post-operative manifest refraction plano-+ sphere-0.25 x-0.50 x-0.75 x-1.00 x-1.25 x-1.50 x-1.75 x-2.00 x-2.25 x-2.50 x-2.75 x-3.00 x-3.25 x-3.50 x

Final aviation uncorrected DVA ODOS 20/ -0-1-2-3/10, *corrects to 20/N/A20 -0-1-2-3/10

Date OSN/A Post-operative manifest refraction plano-+ sphere-0.25 x-0.50 x-0.75 x-1.00 x-1.25 x-1.50 x-1.75 x-2.00 x-2.25 x-2.50 x-2.75 x-3.00 x-3.25 x-3.50 x

Final aviation uncorrected DVA OSN/A 20/ -0-1-2-3/10, *corrects to 20/N/A20 -0-1-2-3/10

Member is asymptomatic with respect to glare or halos from oncoming headlights at night; haze or ghost images; double vision; and vision at twilight. Member is confident in ability to resume aviation duties.

Member has a normal postoperative slit lamp exam.

Member's commanding officer is aware of and concurs with waiver recommendation.

Diagnosis s/p PRK (P1199)s/p LASIK (p1171) OUODOS - CD all aviation duty.

Comments (none required):

Waiver recommended DIACAClass II DIFClass III Service group IService group IIService group IIINaval flight officerNaval aeromedical officerNaval aircrewmemberProject specialistParachute jumperAerospace physiology technicianAir traffic controllerUAV operatorStudent Naval AviatorStudent Naval Flight Officer.

* Corrective lenses required for aviation duty.

Submitting flight surgeon name

Eye care provider name

Senior flight surgeon name