STATE OF NEW YORK DEPARTMENT OF MOTOR VEHICLES 6 EMPIRE STATE PLAZA, ALBANY NY 12228 EYE TEST REPORT FOR MEDICAL REVIEW UNIT MAIL TO: Medical Review Unit, Rm. 220 New York State Department of Motor Vehicles 6 Empire State Plaza Albany NY 12228-0220 (QUESTIONNAIRE FOR PERSONS WITH CORRECTED VISION OF LESS THAN 20/40 BUT NOT LESS THAN 20/70, OR TELESCOPIC LENS WEARERS) INSTRUCTIONS: l This questionnaire must be completed by a physician, ophthalmologist or optometrist, and must be based on an examination performed within 60 days. PLEASE RETURN THE COMPLETED ORIGINAL OF BOTH PAGES OF THIS FORM TO THE MEDICAL REVIEW UNIT AT THE ADDRESS SHOWN IN THE BOX ABOVE. l If this completed questionnaire and all related statements are not returned to the Medical Review Unit (at their address above), your license may be suspended. YOU MUST HAVE APPROVAL FROM THE MEDICAL REVIEW UNIT BEFORE YOU CAN OBTAIN A VALID LICENSE. ALL MEMBERS OF THE LOW VISION PROGRAM ARE REQUIRED TO PROVIDE AN EVALUATION STATEMENT FROM THEIR EYE CARE PROVIDER EVERY 6 MONTHS OR ONCE A YEAR, DEPENDING UPON THE RECOMMENDATION OF THE EYE CARE PROVIDER. MINIMUM STANDARD FOR INDIVIDUALS WITH CORRECTED VISION OF LESS THAN 20/40, BUT NOT LESS THAN 20/70: l Horizontal, binocular field of vision must be no less than 140 degrees. MINIMUM STANDARD FOR TELESCOPIC LENS WEARERS: l l l l l l l l Must have been fitted with, trained to use, and used telescopic lenses for at least 60 days prior to filing this form. For a first-time evaluation, telescopic lens wearers must complete the certification at the bottom of Page 2. Clip-on or hand-held telescopic lenses are not acceptable Visual acuity (Snellen Method) through telescopic portion in either or both eyes must be NO LESS THAN 20/40 Visual acuity (Snellen Method) through carrier lens in either or both eyes must be NO LESS THAN 20/100 Total horizontal, binocular field of vision (no field expanders) must be NO LESS THAN 140 DEGREES Must pass road test if he/she has not taken a road test while wearing his/her telescopic lenses Eligible for a Class D or DJ driver license only Ineligible for a commercial driver license (CDL), a motorcycle license or a moped license. PATIENT — COMPLETE THIS SECTION Please Print or Type Name __________________________________________________________________________________________________ (Last) (First) (M.I.) Address ________________________________________________________________________________________________ (Number and Street) (Apt. No.) ____________________________________________________________________________________________________________ (City) (State) (Zip Code) New York State Client ID # ______________________ MV-80L (5/11) Date of Birth __________________ www.dmv.ny.gov o Male o Female PAGE 1 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com PRACTITIONER — COMPLETE THIS SECTION Patient’s Name____________________________________________________________________ (Last) Date of Birth ____________________ (First) Date of Examination ____________________ (must be within 60 days) Check One: (Month/Day/Year) o Initial Evaluation o Re-evaluation (Month/Day/Year) 1. Visual Acuity (Snellen Method) NOTE: Please check the appropriate box to identify how visual acuity was achieved, then give the visual acuity. o With corrective lenses o Without corrective lenses o With telescopic lenses only Right eye 20/______and/or left eye 20/______ Both 20/______ Through telescopic lenses right eye 20/______and/or left eye 20/______ Through carrier lenses right eye 20/______and/or left eye 20/______ / / 2. If telescopic lenses are used, on what date did patient receive them? ___________________ 3. Does the patient meet or exceed the minimum acceptable horizontal, binocular field of vision of 140 degrees? o Yes o No NOTE: The test object size for determining horizontal, binocular field of vision must be either a white 3 mm size test object at a one-half meter distance, or a white 6mm size test object at a one meter distance, or the equivalent angular size for any test distance. 4. If telescopic lenses, did the patient achieve his/her horizontal, binocular field of vision with the use of field expanders? o Yes o No 5. What medical condition(s) caused the present loss of the patient’s visual acuity?_________________________________________________ _________________________________________________________________________________________________________________ 6. Patient should be re-evaluated every . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o 6 Months o Year 7. Is this condition stable at this time? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . o Yes 8. Check restriction(s) you recommend: o Day Driving Only o Full-View Mirror o No Limited Access Roads 9. In your opinion, would the patient’s condition interfere with the safe operation of a motor vehicle? . . . . . . . . . . . . o No o None o Yes o No If “Yes”, please explain in the space provided, or attach an explanation on your letterhead_________________________________________ ________________________________________________________________________________________________________________ The above information is true, complete and best reflects my professional judgement. ç__________________________________________________________________ _________________________________ (Date) (Practitioner’s Signature) ____________________________________________________________________ _________________________________ (Practitioner’s Name — please print) (Certificate or License Number) ____________________________________________________________________ (_____)___________________________ (Address) (Telephone Number) TELESCOPIC LENS WEARERS MUST COMPLETE THIS CERTIFICATION ONLY FOR A FIRST-TIME EVALUATION I certify that I have successfully completed the minimum training requirements for telescopic lens wearers as outlined in Part 5 of the Commissioner’s Regulations, and that I received the training from: _________________________________________________________________________ (_____)_____________________ (Name of Trainer) (Telephone Number) _______________________________________________________________________________________________________ (Address of Trainer) ç___________________________________________________________________ (Signature of Patient) MV-80L (5/11) _________________________________ (Date Training Completed) PAGE 2 OF 2 American LegalNet, Inc. www.FormsWorkFlow.com