Form 412-Cdl - Report Of Vision Screening For Commercial Driver'S Licenses Or Learner'S Permits

Download a blank fillable Form 412-Cdl - Report Of Vision Screening For Commercial Driver'S Licenses Or Learner'S Permits in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Form 412-Cdl - Report Of Vision Screening For Commercial Driver'S Licenses Or Learner'S Permits with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

South Carolina Department of Motor Vehicles

Report of Vision Screening for

412-CDL

Commercial Driver’s Licenses or Learner’s Permits

(Rev. 9/15)

FORM IS ONLY VALID FOR 12 MONTHS FROM DATE OF VISION SCREENING

***** This form is void if there are any alterations or erasures on it. *****

Applicant’s Name

Date of Birth

Driver’s License Number

Applicant’s Address

City

State

Zip Code

Applicant’s Signature

Date

Telephone Number

THIS SECTION IS TO BE COMPLETED BY A LICENSED EYE CARE PROFESSIONAL

**** Do not return this form to an applicant requiring corrective lenses until new lenses are fitted ****

Applicants must meet the minimum acceptable vision requirements, without the use of a telescopic lens or other attachment, provided below

to obtain and maintain a South Carolina commercial driver’s license (CDL) or CDL learner’s permit.

Federal Motor Carrier Safety Regulation § 391.41 (b)(10) states that the

Distant Vision Only

Right Eye

Left Eye

minimum visual acuity requirements to operate a commercial motor vehicle

are as follows:

Without Corrective Lens

20/

With Corrective Lens

20/

20/40 or better in each eye, with or without corrective lenses; AND



Field of vision must be at least 70 degrees in the horizontal meridian in

New Prescription

20/



each eye.

Field of Vision

DO NOT COMPLETE THIS FORM UNLESS THE APPLICANT’S VISION MEETS THE ABOVE STANDARDS TO OPERATE A

COMMERCIAL MOTOR VEHICLE.

The licensed eye care professional is to answer all of the questions below based on the requirements listed above for a commercial license.

SECTION A – DRIVING RESTRICTIONS

1. Is a corrective lens, such as a conventional type spectacle or a contact lens, needed to operate a commercial motor vehicle?

Yes

SECTION B – PERMANENT SIGHT IMPAIRMENT

2. a) Does the applicant have a permanent sight impairment? ..........................................................................................................

Yes

b) If yes, which eye? …………………………………………………………………………………………………….………….……......

Right

Left

SECTION C – RECHECK VISUAL FITNESS

3. Indicate when the applicant’s eyes should be rechecked to determine visual fitness to operate a motor vehicle.

in 6 months

in 1 year

in 2 years

in 5 years

Other (Comments)

Comments:

Professional No.

being licensed to practice

Printed Name of Licensed Eye Care Professional

in the state of

, certify that

I have performed a vision screening of the eyes of the above named person. This is a true record of this screening and the applicant met the visual

acuity standards without the use of a telescopic lens or other attachment. I further certify that I have answered all of the questions above and that he

or she signed in my presence.

Signature of Licensed Eye Care Professional

Screening Date

Telephone Number

Business Address

City

State

Zip Code