Maryland > Statewide > Motor Vehicle Administration
Vision Screening Form DL-043A - Maryland
| Vision Screening Form Form. This is a Maryland form and can be used in Motor Vehicle Administration Statewide . |
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Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 DL-043A-INT (10-03) Vision Screening Form This form may be used to record: · MVA's vision screening results, if the screening has taken place · Your vision specialist's examination results 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 Field of Vision Continuous? Color vision problems? yes no MVA employee: 20/ 20/ degrees 20/ 20/ degrees 20/ 20/ degrees yes 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) Diagnosis, if applicable: Left Eye Both Eyes Binocular Vision? 20/ 20/ 20/ 20/ 20/ 20/ 20/ 20/ Please Note: The Snellen test must be used yes 20/ no Please do not enter acuities achieved by telescopic lenses in this chart. degrees degrees degrees · Are corrective lenses (standard spectacle) needed to meet vision requirements for driving? yes no If corrected lenses are needed, has this patient acquired the lenses? yes no · Will treatment improve this patient's vision for driving? yes no If yes, please describe: · Does this patient meet the continuous field of vision requirements specified by the MVA? yes no · Did the visual examination reveal any optical or medical reason that could preclude granting a license? yes no (If yes, please submit a complete report for the MVA's Medical Advisory Board.) · Do you recommend any follow-up of this patient's vision status by the MVA's Medical Advisory Board? yes no (If yes, please provide diagnosis.) · For commercial licenses only: Can this patient distinguish between red, green and amber colors? yes no 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: Medicine Ophthalmology Printed Name Optometry in the state of : Date Ophthalmologist/Optometrist's Address Phone Number 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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