Form DSE 1 Notes (Specsavers Voucher Request)

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Section A

This must be completed by the School and duly authorised by the Manager before sending to the

Section B

The employee requests a Specsavers voucher from Employment Support Services at County Hall, presents the voucher to the chosen local store and obtains the necessary eye test and/or spectacles of choice. Vouchers should be used within 1 year of issue and misuse may result in future claims being refused. The duly certified element of the voucher should always be returned for attachment to this form.

No claim will be paid on a DSE2 form for Specsavers Opticians

No additional payments will be made by NYCC.

NorthYorkshireCounty CouncilDSE 1(Specsavers Voucher)

DSE Eye Test Scheme

Section A – to be completed by the Employee

Directorate Location ______

Surname ______Forename ______

Date of Issue ____/____/______Employee Number ______

Authorised by Manager ______Print name ______

Section B – for completion by the employee

Please tick if you wish to receive a Specsavers voucher

The VDU Voucher entitles the holder to:

● Free Eye-test

● If you are found to require glasses specifically and solely for VDU use you are entitled to choose a pair of single vision glasses from the £45 range or if you wish to choose glasses from a higher price range the voucher can be used as a £45 contribution.

● If you are found to require glasses specifically and solely for VDU use and you choose to upgrade to a pair of glasses from the £99 range or over the £45 contribution will increase to a £65 contribution.

● Any employee requiring glasses that are not specifically and solely for VDU use is entitled to a £20 discount if they choose glasses from the £99 range or above.

You also have access to up to 3 Premium Club Vouchers which cover:

● £20 discount to family members selecting glasses from the £99 and above - please note these vouchers cannot be used in conjunction with the VDU eyecare voucher detailed above.

CONDITIONS FOR VOUCHER USE

Section A

  • This must be completed by the employee and duly authorised by theManager before the voucher is issued to the employee.
  • Under no circumstances will North Yorkshire County Council be responsible for paying the optician.

Section B

  • The employee is responsible for obtaining and bringing along their vouchers to their local Specsavers store.
  • All costs will be covered either by the voucher or the employee
  • No additional reimbursement will be paid by NYCC
  • Completed certified vouchers should be returned for matching to this form

Now please forward this completed form to the Employment Support Services at County Hall, Northallerton, DL7 8AD

For office use only:

Vouchers Despatched Certified voucher returned

Signed ____________ Dated ______