Vision Screening Form. This is a Maryland form and can be use in Motor Vehicle Administration Statewide.
Tags: Vision Screening Form, DL-043A, Maryland Statewide, Motor Vehicle Administration
Driver/Patient222s full name: Driver/Patient222s Maryland driver222s license number: MVA Vision Screening Results: Findings from MVA222s Vision Screening ( For MVA use only ) Right Eye Left Eye Both Eyes Field of Vision Continuous? Color vision problems? MVA employee: Acuity without lenses 20/ 20/ 20/ Acuity with present lenses 20/ 20/ 20/ yes no yes no MVA office: Field of Vision (degrees) degrees degrees degrees Date: Vision Specialist222s Examination Results and Certification Exam Date: Please do not enter acuities achieved by telescopic lenses in this chart Right Eye Left Eye Both Eyes Driver222s License Requirements To qualify for an unrestricted driver222s license, the State of Maryland requires drivers to have: Binocular vision Binocular vision Visual acuity (Snellen) of at least 20/40 in each eye Continuous field of vision of 140 degrees Restricted licenses (outdoor mirrors both sides) may be issued to persons having: Visual acuity of at least 20/70 in one or both eyes Continuous field of vision of at least 110 degrees, with at least 35 degrees lateral to the midline of each side Persons with visual acuity less than 20/70, but no worse than 20/100, require special handling by the MVA's Driver Wellness & Safety Division. Acuity without lenses 20/ 20/ 20/ Acuity with present lenses 20/ 20/ 20/ Acuity with best standard spectacle correction 20/ 20/ 20/ Field of Vision (in degrees) degrees degrees degrees For commercial licenses only Does the patient have 20/40 vision or better in EACH eye? yes no Can this patient distinguish between red, green, and amber colors? yes no 1. Are corrective lenses (standard spectacle) needed to meet vision requirements for driving? yes no 1a. If corrected lenses are needed, has this patient acquired the lenses? yes no 2. Does this patient meet the continuous field of vision requirements specified by the MVA? yes no 3. Did the visual examination reveal any optical or medical reason that could preclude granting a license? yes no 3a. If yes, please submit a Maryland MVA DC-220 form. 4. Will treatment improve this patient222s vision for driving? yes no 4a. If yes, Diagnosis/Treatment I certify under penalty of perjury that the information contained hereon is true and accurate to the best of my knowledge, information, and belief. Ophthalmologist/Optometrist222s Signature Printed Name Date Licensed to practice: Ophthalmology Optometry License State/Number: Ophthalmologist/Optometrist222s Address Phone Number For more information, please call: 410-768-7000 (to speak with a customer agent). TTY for the hearing impaired: 1-800-492-4575. Visit our website at: www.MVA.Maryland.gov Motor Vehicle Administration 6601 Ritchie Highway, N.E. Glen Burnie, Maryland 21062 Vision Screening Form DL - 043A ( 08 - 1 8 ) American LegalNet, Inc. www.FormsWorkFlow.com