Vision and Lighting Assessment Form
Please complete this form to assess the vision and lighting conditions of the designated environment.
Assessor's Full Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Assessment Location (e.g., Room, Area, Building)
*
Purpose of Assessment
*
Please Select
Routine Check
Complaint Investigation
New Installation Review
Other
Type of Environment
*
Office
Classroom
Industrial/Workshop
Healthcare Facility
Retail
Other
Lighting Sources Present (Select all that apply)
*
Natural Light (Windows/Skylights)
Overhead Fluorescent
LED Fixtures
Desk/Task Lamps
Other
Vision and Lighting Evaluation Table
*
Rows
Excellent
Good
Fair
Poor
General Visibility
1
2
3
4
Lighting Level (Brightness)
5
6
7
8
Color Rendering
9
10
11
12
Presence of Glare
13
14
15
16
Shadows/Contrast
17
18
19
20
Visual Comfort
21
22
23
24
Are there any areas with insufficient lighting?
*
No
Yes (please specify below)
If yes, please describe the areas with insufficient lighting.
Rate your overall satisfaction with the lighting conditions
*
1
2
3
4
5
Additional Comments or Recommendations
Assessor's Signature
*
Submit Assessment
Submit Assessment
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