Please note: To receive a voucher, you must complete both (a) Form PD41 and (b) DSE Self-Assessment Form in full Send both forms to Health and Safety team before your optician’s appointment is booked Once the Health and Safety Team receives these forms a pre-paid Specsavers voucher will be sent to your email address. You should then book your test You will need to give this voucher to your Specsavers Optician at the time of your appointment – either print out or show it via smart phone This process cannot be carried out in retrospect. Do not attend the test without the voucher Please note there is an expiry date, and the voucher should be used within 3 months of receiving it. If not used within that timeframe, please return to Health and Safety team The eye care voucher is only valid at Specsavers
Employee name:
University email address:
College / Service:
Please tick to confirm one of the following: I have a University of Exeter Contract of Employment. Or I am a member of the University of Exeter Doctoral College.
Please read and tick both the following check boxes: I consider that I habitually use display screen equipment as a significant part of my normal work (i.e. for continuous periods of an hour or more at a time) and I request an eye examination and sight test to be carried out at a branch of Specsavers. I have completed the attached Display Screen Equipment (DSE) workstation self-assessment and provided a copy to my line manager. (see DSE Guidance Pages for Self-Assessment form and instructions)
Number of days / hours worked per week:	Days	Hours
Approximate number of hours per day spent using a VDU at work:	Hours	Days
I normally wear spectacles or contact lenses for reading and/or general use	Yes	No
Approximate date of last eyesight test:
Click Submit to e-mail this completed form to the Health and Safety Team, and copy to line manager For further information and troubleshooting click the Help button
SIGN AND DATE ONLY IF COMPLETED MANUALLY AND POSTED
Employee’s signature: Not needed if form is emailed
Date:
Post to:	Health and Safety, Hope Hall, Streatham Campus

Receive your glasses. Retest in 2 years. Corrective lenses needed for general long/short sight, not VDU work Choose frames costing less than £99. Pay for these frames and lenses yourself. Use £20 Premium Club Voucher to get discount on frame costing £99+ at Specsavers or Take your prescription elsewhere. Corrective lenses required solely for VDU use at work Choose Specsavers frames from £45 - £89 range at no further cost or Choose frame costing £99+ and receive £45 discount on total cost (plus £20 Premium Club Voucher STC) and pay the rest. Complete eye and sight examination at Specsavers. Receive prescription (if required) No corrective lenses required for VDU use. Retest in 2 years. Conduct a DSE Self-Assessment. Pass a copy to your line manager or supervisor and enclose a copy with this form PD41 when you send it to the Health and Safety team (safety@exeter.ac.uk) Actions arising from the DSE Self-Assessment should be completed Complete the DSE eye care voucher request form (PD41) see the page above Attach a copy of your completed DSE Self-Assessment form and send it with the completed PD41 to safety@exeter.ac.uk Await the return of Specsavers e-Voucher from the Health and Safety team (up to 10 days) Print e-Voucher or use smart phone to show Specsavers staff