Free Report of Eye Evaluation - Federal

INFORMATION FOR APPLICANT


REPORT OF EYE EVALUATION

Privacy Act Statement
Information requested on this form is solicited under the authority of Title 49 of the United States Code (Transportation) sections 109(9), 40113(a), 44701-44703, and 44709 (1994) formerly codified in the Federal Aviation Act of 1958, as amended, and Title 14 of the Code of Federal Regulations (CFR), Part 67, Medical Standards and Certification. Submission of this information is mandatory and incomplete submission will result in delay of consideration of or denial of application for an airman medical certificate. The purpose of this information is to determine whether an applicant meets Federal Aviation Administration medical requirements to hold an airman medical certificate for further consideration under 14 CFR 11.53 and 67.401. It is also used to depict airman population patterns and to update certification procedures and medical standards. The information collected on this form becomes a part of the Privacy Act System of Records DOT/FAA 847, General Air Transportation Records on individuals, and is provided the protection outlined in the system's description as published in the Federal Register.

Paperwork Reduction Act Statement: Applicants not meeting the distant visual acuity standards
and who desire an Authorization for Special Issuance of a Medical Certificate (Authorization) must submit FAA Form 8500-7, Report of Eye Evaluation, for evaluation and determination by the FAA. Submission of information is mandatory. The purpose of this information is to determine whether an applicant meets FAA medical requirements to hold an airman medical certificate for further consideration under Title 14 of the Code of Federal Regulations (CFR) 11.53 and 67.401. Any person who is denied a medical certificate by an aviation medical examiner may appeal to the Federal Air Surgeon under 14 CFR 67.409, Denial of medical certificate. This information is also used to depict airman population patterns and to update certification procedures and medical standards. If you wish to comment on the accuracy of the estimate or make suggestions for reducing this burden, please direct your comments to the FAA at the following address: Federal Aviation Administration; Aeromedical Certification Division, AAM-300; P.O. Box 26080; Oklahoma City, OK 73126-9922. The public reporting burden for collection of information is estimated to average 15 minutes per response. The agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The paperwork burden associated with this form is currently approved under OMB number 2120-0034. Comments concerning the accuracy of this burden and suggestions for reducing the burden should be directed to the FAA at: 800 Independence Ave SW, Washington, DC 20591, Attn: Information Collection Clearance Officer, ABA-20

Tear off this cover sheet before submitting this form

FAA FORM 8500-7 (3-06) Supersedes Previous Edition

04/30/2011