Form 999 - Vision Examination Record printable pdf download

MISSOURI DEPARTMENT OF REVENUE

DRIVER LICENSE BUREAU, P.O. BOX 200

TELEPHONE: (573) 751-2730

FORM

301 WEST HIGH STREET, ROOM 470

FAX: (573) 522-8174

999

JEFFERSON CITY, MO 65105-0200

WEB SITE:

VISION EXAMINATION RECORD

(REV. 05-2013)

PATIENT NAME (LAST, FIRST, MIDDLE)

SOCIAL SECURITY NUMBER

DATE OF BIRTH (MM/DD/YYYY)

DRIVER OR

__ __ __ - __ __ - __ __ __ __

__ __ / __ __ / __ __ __ __

PATIENT

PATIENT MAILING ADDRESS

CITY

STATE

ZIP CODE

SECTION

__ __ __ __ __

I hereby authorize and accept that:

• My physician will conduct an eye examination to determine if my visual abilities are adequate to operate a motor vehicle safely

and responsibly.

• The Driver License Bureau will make a final decision concerning my eligibility for driver licensure based on all available information.

Date (MM/DD/YYYY)

___ ___ / ___ ___ / ___ ___ ___ ___

_______________________________________________________________

Signature of Driver or Patient (must be signed in the presence of physician)

Yes No

Are you a regular or primary eye care provider for this patient?

PHYSICIAN

If yes, how many times have you seen this patient in the past year?

SECTION

If no, are you evaluating this patient for the first time today?

Yes No

Remarks: (special restrictions, severity, stability, etc.)

Distance Acuity

LEFT

RIGHT

BOTH

W/O Correction

20/

With Correction

20/

Horizontal Field

Width

VISION GUIDELINES

Corrective lenses (A)

20/40 or better in either eye, or both, corrected

Left outside mirror (Y)

20/100 or worse in left eye only, no aid or corrected

Right outside mirror (T)

20/100 or worse in right eye only, no aid or corrected

20/41 to 20/59

Daylight driving only (AC)

20/60 to 20/74

Daylight driving only, restricted 45 mph (ACF)

Based on my observations of this patient or information relayed to me by this individual, I, reasonably and in good faith, believe that he

or she is:

LIKELY CAPABLE of operating a motor vehicle safely and responsibly. There are no visual contradictions at this time.

No further evaluation appears to be needed.

UNCLEAR IF CAPABLE of operating a motor vehicle safely and responsibly due to current visual status.

NOT CAPABLE of operating a motor vehicle safely and responsibly due to a significant visual compromise or deficit.

If you are unclear if the patient is capable of operating a motor vehicle safely please submit a copy of this form to:

DLB.DriverReviewProcessing@dor.mo.gov or mail to the address above.

OFFICE MAILING ADDRESS (INCLUDING ZIP CODE)

SPECIALITY

LICENSE NUMBER

PHONE

FAX

( __ __ __) __ __ __ - __ __ __ __

PHYSICIAN NAME (PRINTED)

SIGNATURE

DATE (MM/DD/YYYY)

__ __ / __ __ / __ __ __ __

For further information on Department policies and restrictions go to

DOR-999 (05-2013)

Form 999 - Vision Examination Record

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