Prescription Safety Glasses Program

Supervisor's Authorization Form

[Download the PDF version]

All requests for prescription safety glasses must be approved by the requestor's supervisor before an order for the prescription safety glasses is placed. Once this completed form is received by the Primary Processor an email authorization will be sent to the requestor, requestor's supervisor, and the contracted optometrist.

The Primary Processor will charge back the cost for the prescription safety glasses to the requestor's department. A valid campus PTA must be provided before an authorization form will be issued to the requestor.

Please note: requestor must have a current (within the past 18 months) eyeglass prescription. Anything beyond that date OR a condition that requires monitoring will need a more current Rx.

Requestor's Full Name: _______________________________________________________
Requestor's UID: ________________________________________________________________
Department: ______________________________________________________________________
Mail Bode: __________________________________________________________________________
Phone Number _____________________________________________________________________
Supervisor's Full Name: ____________________________________________________________
PTA: _______________________________________________________________________________

I hereby authorize the purchase of prescription safety glasses for the individual listed above. This authorization includes:

☐ Standard Safety Glasses

☐ Progressive Lenses (Bi-Focal)

☐ Transition Lenses

☐ Anti-Reflection Coating

☐ Limit total cost (not to exceed) $ __________ ___________________

Supervisor's Signature _ _________________________________________

Date Signed ____________________________