Employee Instructions:

• Eye tests are eligible for reimbursement every 2 years for staff using VDU/screens for long periods.
• Tests must be conducted in the employee’s own time.
• Reimbursement is matched to Specsavers or equivalent “like-for-like” service rates.
• Original receipts must be attached to this form.

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Section 1: Employee Details

Glasses Are Name

Full Name *

First

Last

Job Title *

Department/Location *— Select Choice —Head OfficeFarm View DNFoxley DNMaidenhead DNOldfield ASCCourthouse ASCFurze Platt ASC

Section 2: Eye Test Reimbursement

Date of Eye Test *

Provider Name *

e.g. Specsavers

Cost of Eye Test *

(Note: A full receipt must be provided showing the vision test and eye examination)

Section 3: Prescription Glasses (If Applicable)

Only applicable if the optometrist confirms that special glasses are required specifically for Visual Display Unit/screen distance.

Are these glasses specifically for VDU use?

• Yes
• No

Visual Display Unit (VDU)

Cost of Lenses

Cost of Frames

Wise Owls will pay a maximum of £50.00 for frames

Total Glasses Claim *

Including the cost of Eye Test

Attach Receipt *

Drag & Drop Files, Choose Files to Upload

Section 4: Employee Declaration

I confirm that the above eye test was completed in my own time and that the information provided is accurate. If claiming for glasses, I confirm they have been prescribed specifically for screen/VDU work.

Name *

Date *

Signature

Clear Signature

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