Display screen equipment
/
Request for eyesight test
To be completed by authorised manager
Employee name (please print) / Payroll reference number
DSE user / Yes/ No
To be completed by the Optician
I confirm that I have examined the above patient's eyes and recommend the following:
Are spectacles required? / Yes / No
Spectacles for use with DSE / Yes / No
Type of spectacles required: / Single Vision / varifocals *
Re-examination recommended: / Months/ Years
Optician's signature: / Date

* Varifocal/Bifocal spectacles are considered acceptable for DSE use where specifically prescribed for that use by the dispensing optician.

Optician’s stamp
Summary – reimbursement
Amount to be reimbursed: £
Employee's signature / Date
I confirm as the manager that the receipt for the payment of the eyesight test/ glasses (delete as applicable) has been given to me and this will kept on file for audit purposes (max reimbursement for spectacles £60)
Authorised Manager's name (please print)
Authorised Manager's signature / Date

Guidance on making claim for eyetest reimbursement

  1. DSE Users (see the policy for definition of User) are entitled to request that their eyes are tested to check if they need spectacles to see the screen clearly.
  2. Staff will only be reimbursed for the cost of a basic eyesight test.
  3. Staff can request a retest at regular intervals recommended by their optometrist, normally every two years.
  4. Staff who need spectacles specifically to see a screen clearly can claim £60 towards the cost. Staff who purchase spectacles that are more expensive have to cover any additional costs themselves. Reimbursement is not available for contact lenses. Reimbursement is not available for spectacles that are for general use or which are not worn when using Display Screen Equipment.
  5. Staff who are recommended bifocal or varifocal spectacles by their optometrist should ensure that the main area of the spectacles are specifically set to enable them to see the screen clearly.

Procedure for reimbursement

Employee

1)Take this form to the optician for completion, remembering to collect a payment receipt as proof of purchase.

2)Complete the remainder of this form as directed.

3)Show this form and your payment receipt to your line manager as proof that the test has been completed.

4)Keep the original eyetest form and the payment receipt for audit purposes.

Line manager

1)Once this form has been completed go to the IBC Portal, use the ‘Manage one payments’ app, you can then select the relevant employee to reimburse. Guidance can be found here for completing this one off payment.

2)Return this form to the employee so that they can keep it for audit purposes.

Issue 5

May 2014