Form Co/dv-135 - Kansas Division Of Vehicles Vision Form
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1KANSAS DIVISION OF VEHICLES VISION FORM
__________________________________________________________
Name of Applicant:
DL#:
_____________
Applicant Address:
__________________________________________________________
DOB:
_____________
Are you enrolled in Driver’s Education? YES ☐ NO ☐
Instructor’s Name: ________________________________
Instructor’s Phone #: _____________________________________________________
Applicant: Your signature is your release for eye doctor to give your vision information________________________________________________
___________________________________________________________________________________________________________________________
IF RENEWING: YOU MAY RECEIVE YOUR VISION TEST FREE OF CHARGE AT THE DRIVER LICENSE EXAMINING STATION. If you fail
to test 20/40 in at least one eye at the examining station, you will be required to take THIS FORM to a vision specialist. If you fail to test 20/60 in at least
one eye by the vision specialist, your report may be forwarded, by the Examiner, to the DIVISION OF VEHICLES. An examination administered within
the past 90 days is required.
FOR ANNUAL REVIEWS: Please have this form completed by your eye specialist. Return completed form, within sixty (60) days, to the DIRECTOR
OF VEHICLES for review and recommendations regarding your driving privileges. Recent exam required (Within past ninety (90) days). Please fax
completed exam to (785) 296-5857 or mail to Medical / Vision Unit PO Box 2188 Topeka, Ks. 66601-2188. Processing time is 7 – 10 business days.
INSTRUCTIONS FOR LICENSED OPTOMETRIST/OPHTHALMOLOGIST
Please sign this report after completing the questions on the form below. No recommendations or suggestions as to which specialists to visit are given by
the Driver License Examiners. The eye specialist assumes no liability in making this report. See Kansas Statute Section 8-247 (d) (6).
VISION FORM TO BE COMPLETED BY OPTOMETRIST OR OPHTHALMOLOGIST
Acuity Right Eye
Left Eye
Both Eyes
Horizontal Field of Vision
Present Lenses:
20/____
20/____
20/____
Right of Fixation: _______________
Without Lenses:
20/____
20/____
20/____
Left of Fixation: ________________
Best Correction:
20/____
20/____
20/____
Total Angle: ___________________
Bioptic/Telescopic: (If
20/____
20/____
20/____
prescribed for driving)
Driver wears contact lenses or glasses for correcting vision.
YES☐
NO☐
Driver must take and pass a drive test at a Kansas Exam Station.
YES☐
NO☐
Diagnosis of visual condition: _________________________________________________________________________________
YES ☐
NO ☐
In my professional opinion, I believe this person can safely operate a motor vehicle at
this time in regards to their current vision reading. (Driver must be considered a safe
candidate in order to request a drive test.)
(This question may be omitted if visual acuity is better than 20/60 in at least one eye and visual angle is greater than 110°.
Applicant must also meet all other qualifications required for issuance of a driver's license as determined by the Driver's License
Examiner or the Director of Vehicles.)
An Annual Vision Report should be required:
YES ☐
NO ☐
YES ☐
NO ☐
Applicant’s physical / medical condition should be evaluated:
Recommendations / Restrictions to be placed on the license if issued:
(Limit 6)
☐Corrective Lenses
☐ Within City Limits
☐ Outside Mirror
☐Daylight Hours Only
☐ Licensed Driver in Front Seat
☐ Automatic Transmission
☐No Interstate / Freeway Driving
☐ Mechanical Aid
☐ ( ___ )Miles from Home
☐Outside Business Area
☐ Prosthetic Aid
(5-30 in 5 mile increments)
_________________________________________________________
__________________________________________________________
Name of Optometrist / Ophthalmologist (Please print)
Date of Examination (Within the last 90 days)
__________________________________________________________
Address
__________________________________________________________
__________________________________________________________
Signature of Optometrist / Ophthalmologist
Phone:____________________________________________________
Date Signed: _______________________________________________
CO/DV-135 Rev. (09/15)
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