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Vision Screening Form DL-043A - Maryland

Vision Screening Form Form. This is a Maryland form and can be used in Motor Vehicle Administration Statewide .
 Fillable pdf Last Modified 1/23/2014
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Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 DL-043A (04-12) Vision Screening Form This form may be used to record: · MVA's vision screening results, if the screening has taken place Driver/Patient's full name: Driver/Patient's Maryland driver's license number: MVA Vision Screening Results: Findings from MVA's Vision Screening (For MVA use only) Right Eye Acuity without lenses Acuity with present lenses Field of Vision (degrees) Left Eye Both Eyes MVA employee: · Your vision specialist's examination results 20/ 20/ degrees 20/ 20/ degrees 20/ 20/ degrees Field of Vision Continuous? Color vision problems? r yes r no r yes r no MVA office: Date: Vision Specialist's Examination Results and Certification Vision Exam Date: Right Eye Acuity without lenses Acuity with present lenses Acuity with best standard spectacle correction Field of Vision (in degrees) Left Eye Diagnosis, if applicable: Both Eyes Binocular Vision? 20/ 20/ 20/ degrees 20/ 20/ 20/ degrees 20/ 20/ Please Note: The Snellen test must be used r yes 20/ r no degrees Please do not enter acuities achieved by telescopic lenses in this chart. · Are corrective lenses (standard spectacle) needed to meet vision requirements for driving? r yes r no If corrected lenses are needed, has this patient acquired the lenses? r yes r no · Will treatment improve this patient's vision for driving? r yes r no If yes, please describe: · Does this patient meet the continuous field of vision requirements specified by the MVA? r yes r no · Did the visual examination reveal any optical or medical reason that could preclude granting a license? r yes r no (If yes, please submit a complete report for the MVA's Medical Advisory Board.) · For commercial licenses only: Can this patient distinguish between red, green and amber colors? r yes r no Even if this individual is presently eligible to renew by mail, I understand I may contact the Medical Advisory Board for follow-up if I later detect any change in visual acuity that may affect fitness to drive. I certify under penalty of perjury that the information contained hereon is true and accurate to the best of my knowledge, information and belief. Ophthalmologist/Optometrist's Signature Licensed to practice: r Medicine Printed Name Date r Ophthalmology r Optometry in the state of : Phone Number Ophthalmologist/Optometrist's Address For more information, please call: 1-800-638-8347 (touch tone calls only), 1-800-950-1MVA (1682) (to speak with a customer service representative), From Out-of-State: 1-301-729-4550, TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.marylandmva.com American LegalNet, Inc. www.FormsWorkFlow.com
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