Free Certificate of Vision Examination by Competent Authority - Wisconsin


File Size: 61.0 kB
Pages: 1
File Format: PDF
State: Wisconsin
Category: Government
Author: WisDOT
Word Count: 441 Words, 2,715 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.dot.wisconsin.gov/drivers/forms/mv3030v.pdf

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CERTIFICATE OF VISION EXAMINATION BY COMPETENT AUTHORITY
MV3030V 5/2008 Ch. 343 Wis. Stats. and Trans. 112 Admin. Code APPLICANT: You may be required to file vision reports on a regular basis. We will send you the forms at the time they are required.

Clear Form

Incomplete forms will be returned for completion.
Name Operator License Number

Wisconsin Department of Transportation Medical Review PO Box 7918 Madison WI 53707-7918 Telephone: 608-266-2327 FAX: 608-267-0518 E-Mail: [email protected]

Street Address

Birth Date

City, State ZIP Code

Area Code - Telephone Number

Date Issued

Examiner Badge Number

License Type Instruction Permit

Operator

CDLI CDL

Passenger Bus

School Bus

Minimum standards for non-commercial drivers - 20/100 vision or better in at least (1) one eye and 20° field of vision from center of at least (1) one eye. Minimum Wisconsin standards for commercial drivers (applies to drivers grandfathered or exempted by federal or state law) - 20/60 vision or better in at least (1) one eye and 70° field of vision from center of at least (1) one eye. Minimum federal and school and/or passenger endorsement standards - 20/40 vision or better in each eye, 70° field of vision from center in each eye and ability to distinguish traffic signal colors. Bioptic lenses may not be used to meet standards. All standards refer to the best vision with or without corrective lenses. Report must be completed based on an examination conducted within the past 90 days or since ______________. VISION SPECIALIST: The Secretary of the Department of Transportation is, by statute, responsible for the decision of driver licensing. Your report will be advisory in determining eligibility. Indicate Snellen Chart Figures Visual Acuity Right Eye Left Eye
Yes No

Without RX 20/ 20/

With RX 20/ 20/

Temporal Field of Vision In Degrees

1. Does applicant have progressive eye condition(s)? If yes, what? 2. Is applicant able to distinguish traffic signal colors or red, amber and green? 3. Is applicant safe to operate a non-commercial motor vehicle? 4. Is applicant safe to operate a commercial motor vehicle? 5. Is applicant safe to operate a passenger and/or school bus? 6. Re-examination by DOT (knowledge, highway signs & road test) 7. Recommended restrictions: Miles from home Comments: Corrective lenses Other: Daylight Driving Only

Specialist - Print Name

Check One: MD

Medical License Number

OD

APNP
Area Code - Office Telephone Number

Office Address

Specialist - Signature

Patient Examination Date: Month - Day - Year

X Pursuant to s.448.01(5) and s.449.01(1) Wis. Statutes and Trans Ch. 112.02(16) Wis. Admin. Code, this form must be signed by an MD, OD or APNP.
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