Cdl Vision Screening Certificate -Registry Of Motor Vehicles Page 2
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1
25.
Can the applicant distinguish red, green, and amber colors?
YES
NO
(Check One)
NOTE: T
, “YES”
5.
O OBTAIN A LICENSE
MUST BE CHECKED TO QUESTION
Listed below are the conditions, treatment, or medication plan, which the applicant must follow in order to maintain the validity of
my professional opinion:
A license is valid for five (5) years.
Do you think that the applicant should be re-evaluated by the Registry during that time period?
YES
NO (Check One)
If “YES”, please complete:
“I recommend a re-evaluation on
(month/year) due to
(condition/
disease) and
(other factors/comments).”
VISION SCREENING ANALYSIS
Provided said applicant follows the conditions and treatment prescribed on this certificate, in my professional opinion the
operator meets the minimum visual standards required by the Federal Motor Carrier Safety Administration (described above)
and therefore is visually qualified to safely operate commercial vehicles.
______ YES
______NO
I, the undersigned ophthalmologist or optometrist, agree to keep a copy of this Vision Screening Certificate in my office for a one-
year period following the date of the screening.
I hereby certify that the information provided herein is true, accurate, and complete,
(MASSACHUSETTS REGISTRATION #)
(SIGNATURE OF OPHTHALMOLOGIST OR OPTOMETRIST)
(DATE OF SCREENING)
(PRINTED/TYPED NAME OF OPHTHALMOLOGIST OR OPTOMETRIST)
(
)
Circle one:
M.D
O.D.
(OFFICE PHONE)
NOTE: THE REGISTRY WILL NOT ACCEPT THIS CERTIFICATE AFTER TWELVE MONTHS FROM DATE OF
SCREENING.
A PHOTOCOPY OF THE CERTIFICATE WILL NOT BE ACCEPTED.
ONLY A
CERTIFICATE WITH ORIGINAL WRITING WILL BE ACCEPTED.
Please be advised that Massachusetts may waive the federal visual standards for INTRASTATE commerce if the individual has a
combined horizontal peripheral field of vision of not less than 120 degrees; provided the individual also has a distant visual acuity
of at least 20/40 (Snellen) in either eye, with or without corrective lenses, and the ability to distinguish the colors red, green, and
amber. The federal government also has a vision exemption program for INTERSTATE driving. To learn more about the federal
program, visit their website at
To Be Completed By RMV Personnel Only:
REVIEWED AT
OFFICE ON
BY ______________________
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