Fillable Printable Cdl Sbus Vision Waiver Packet
Fillable Printable Cdl Sbus Vision Waiver Packet
Cdl Sbus Vision Waiver Packet
AN EQUAL OPPORTUNITY EMPLOYER
STATE OF MINNESOTA
DEPARTMENT OF PUBLIC SAFETY
HOW DO I OBTAIN A VISION WAIVER TO DRIVE A
SCHOOL BUS OR TYPE III SCHOOL BUS IN MINNESOTA?
Step 1:
If you have not already done so, you must have a medical examination by a licensed physician at some point within the two years
preceding the date of application to assure that you have no other disqualifying medical conditions. The complete medical
examination must include a review of all items listed in Code of Federal Regulations, title 49, section 391.41.
Include a copy of the MEDICAL EXAMINATION REPORT-For Commercial Driver Fitness Determination
with your waiver
application.
Step 2:
Complete the attached School Bus and Type III School Bus Driver Medical Waiver Application.
Step 3:
Submit
one of the following:
1. A legible copy of both sides of your current commercial driver's license, OR
2. A legible copy of both sides of the license you last possessed to operate a commercial motor vehicle, OR
3. A certification from the State licensing agency showing the type and effective date of the most recent license you have held.
Step 4:
Complete the attached Vision Waiver Application.
Step 5:
You must have an eye examination performed by an Optometrist or Ophthalmologist and attach the Optometrist or
Ophthalmologist Report dated within the past six months.
V1 (Vision Impairment Cover Letter revised 2015)
Mailing Address:
445 MINNESOTA ST., SUITE 180
ST. PAUL, MN 55101-5180
Phone: (651) 297-5029 | TTY: (651) 282-6555
Fax: (651) 282-2110
Email:
After these steps have been completed, forward all application information for the vision waiver to
the address above. The information will be reviewed and you will be notified of the department's
decision by mail. If a waiver is issued, you must comply with its terms and conditions.
Incomplete applications will be returned and may result in a waiver not being issued.
NOTE: If you have been granted a waiver by the regional director of Motor Carriers from Code of Federal Regulations, title 49,
section 391.41, (b) (1) or (2) (loss of a limb or limb impairment), an original or photo copy of the waiver issued by the United
States Department of Transportation may be submitted in lieu of the state limb impairment waiver.
Print Form
School Bus and Type III School Bus Driver Medical Waiver Application
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
G (General Application revised 2015)
(over)
I am applying for a waiver of the medical condition described in this application, as provided for in Minnesota Rule
7414.1410. Except for the condition described herein, I am otherwise medically qualified to operate a school bus or Type
III school bus within the state.
B. Medical Condition Information
1. Specify the physical qualifications for which a waiver is requested.
2. Describe your disability or impairment.
Print this completed form and submit to Driver and Vehicle Services via: Email: [email protected], Fax: (651) 282-2110, or
Mail or Deliver in person: Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5180
• This application is to be used for waiver requests of the requirements in Minnesota Rules 7414.1200 and Code of Federal
Regulations, title 49, section 391.41.
• Additional application information and forms must be completed if the condition involves a limb impairment, insulin-dependent
diabetes, or vision. No waiver is granted for the hearing requirement.
• Incomplete applications will be returned and may result in a waiver not being issued.
• Attach additional information as needed.
• If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY)
A. Driver Applicant Information
Full Name
Street Address City / State / Zip Code
Date of Birth (mm/dd/yy)
Daytime Phone (include area code)
License Expiration Date (mm/dd/yy)
Email Address
Driver's License Number
- -
- -
Waiver Applicant's Signature
Date (mm/dd/yy)
G (General Application revised 2015)
Attach additional information as needed.
X
3. Describe the school bus or Type III school bus you intend to drive, including passenger capacity and gross vehicle weight,
if known.
4. Estimate the period of time, per day, that you will be driving and on duty.
5. Provide your driving record for the last three years, including driving records from other states, if applicable.
6. Provide the medical examination performed according to Minnesota Rules part 7414.1200 and Code of Federal
Regulations, title 49, section 391.41 -- and a copy of the certificate from the examining physician attesting that you are
otherwise qualified, except for the disability or impairment for which a waiver is requested.
7. Provide a copy of your road test as prescribed by Driver and Vehicle Services.
8. Describe the alternative measures; modification of policies, practices, or procedures; or the provision of auxiliary aids or
services that will be taken to ensure there is no significant risk to the health and safety of the public and pupils, should the
waiver be granted.
School Bus and Type II School Bus Driver
Medical Waiver Application
Vision Waiver Application
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
A. Driver Applicant Information
Full Name
Street Address City / State / Zip Code
Date of Birth (mm/dd/yy)
Daytime Phone (include area code)
License Expiration Date (mm/dd/yy)
Email Address
Driver's License Number
- -
- -
Print this completed form and submit to Driver and Vehicle Services via: Email: [email protected], Fax: (651) 282-2110, or
Mail or Deliver in person: Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5180
B. Vision Condition Information
• This application is to be used for a waiver request of the requirements in Minnesota Rules 7414.1200 and Code of Federal
Regulations, title 49, section 391.41.
• Except for the vision impairment described herein, I certify that I am otherwise medically qualified to operate a school bus or Type III
school bus within the state.
• Incomplete applications will be returned and may result in a waiver not being issued. Attach additional information as needed.
• If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY)
V2 (Vision Waiver Application revised 2015)
I had an eye examination performed by an Optometrist or Ophthalmologist within the past six months.
Attached is the Optometrist or Ophthalmologist Report that:
1. Identifies my visual deficiency.
2. Certifies that my visual acuity is at least 20/40 Snellen, corrected or uncorrected, in the better eye.
3. Certifies that my field of vision is no less than 120 degrees in one or both eyes together as demonstrated on a
Goldman perimeter using an IIIe target, or equivalent full field test using an automated perimeter.
4. Certifies that I recognize the colors of red, green, and amber in traffic signals in an actual field test if I failed a color
screening test or comparable color contrast sensitivity test.
5. In the opinion of the optometrist or ophthalmologist, I can safely perform the required normal school bus or Type III
school bus driver operations.
The information I have provided in this application is true and correct to the best of my knowledge.
Signature of Waiver Applicant
Date (mm/dd/yy)
X
Vision Report
Section A - (Reverse Side) Must be completed and signed by patient in the presence of the vision examiner
Section B - (Reverse Side) Must be completed and signed by a licensed vision examiner
Minnesota statutes may require driving restrictions other than those recommended by the licensed vision examiner
Submit the form:
By mail: send to the address listed above
By Fax: (651) 282-2463
In person: Bring to any Driver's License Exam Station
All the information collected on this form is required by law. This data is used by authorized Driver and Vehicle Services division
personnel to ensure that those with insufficient vision take the steps required to achieve the best vision possible and to deny
driving privileges to those whose vision is likely to interfere with the safe operation of motor vehicles.
(Minnesota Statutes, chapters 171.04, 171.13, and 171.14; Minnesota Rule 7410.2400)
All data collected on this form is private and may not be issued to anyone, with the exception of name and address, which may
be provided to law enforcement personnel.
A driver's license will not be issued until a satisfactory report is submitted.
Restriction Information - For complete information see Minnesota Rule 7410.2400
Daylight Restriction: Visual acuity of 20/50 or less may be restricted to daylight hours.
Speed Restriction: Visual acuity of 20/50 or less corrected vision in one usable eye or both eyes, or visual field of less
than 105 degrees. 20/50: 55 miles per hour 20/60: 50 miles per hour 20/70: 45 miles per hour
Area Restriction: Visual acuity of 20/50 or less may be restricted to driving within a certain area equal to or less than
the speed restriction. For example, a person limited to a maximum speed of 45 miles per hour or less is prohibited from
driving on any freeway, expressway, or limited access highway that has a speed limit of more than 45 miles per hour.
Road Restriction: Drivers with speed restrictions may also be restricted to driving on roads that have a speed limit.
Equipment Restriction: Field of vision between 100 and 105 degrees in the horizontal diameter with either one
usable eye or with both eyes - requires left and right outside rearview mirrors on vehicle.
PS30338-17 (10/16)
COMPLETE REVERSE SIDE
u
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
Phone: (651) 296-2025 Fax: (651) 282-2463 TTY: (651) 282-6555
Web: dvs.dps.mn.gov Email: [email protected]
DRIVER AND VEHICLE SERVICES
445 Minnesota Street, Suite 180
Saint Paul, MN 55101-5180
DATA PRIVACY
Print Form
SECTION A - TO BE COMPLETED BY PATIENT (Please Print)
SECTION B - TO BE COMPLETED BY LICENSED VISION EXAMINER
- - - -
MINNESOTA DRIVER'S
LICENSE NUMBER:
BIRTH DATE:
Full Name:
Street Address:
City:
State:
Zip:
Patient's Signature (MUST be signed in the presence of the vision examiner).
X
Phone Number:
Date of Last Vision Exam
Must have been within six months:
Right Eye:
Left Eye:
Both Eyes:
Without
Corrective Lenses
With Present
Corrective Lenses
With New
Corrected Lenses
Right Eye: 20/ 20/ 20/
Left Eye: 20/ 20/ 20/
Both Eyes: 20/ 20/ 20/
P e r i p h e r a l V i s i on
Horizontal Fields in Degree
V i s i o n A c u i t y
Is your patient's vision adequate to exercise reasonable and proper control of a motor vehicle? (Please check one)
No, reason:
Yes, without corrective lenses
Yes, with present corrective lenses
Yes, with new corrective lenses
The patient should be required to submit this form every: (check one)
Recommended Restrictions: (Please mark all that apply)
Daylight Only
Maximum Speed mph Limit to miles from home No Freeway Driving
Other (specify)
VISION PROBLEMS
Please identify any condition that is impairing your patient's vision (i.e., cataracts present, macular degeneration,
diabetic retinopathy, peripheral vision impairment, etc.).
What affect does your patient's condition have on his/her ability to see while driving? (i.e., tunnel vision, blurred vision,
blank spots, etc.)?
The condition is (please check one):
STABLE
PROGRESSIVE
Is there treatment that would improve your patient's vision?
NO YES
Anticipated date when treatment will be complete:
Has treatment been scheduled?
NO YES
Vision Examiner's Name:
Office
Address
:
Vision Examiner's Signature
Date
License
Number
:
Phone Number:
Street City State Zip Code
If your patient's vision is 20/80 or up to but not including 20/100, please answer following questions:
X
PS30338-17 (10/16)
4 years 3 years 2 years 1 year 6 months
No restrictions (specify)
VISION REPORT
Yes, with bioptics (Note: Restrictions are based on vision acuity with carrier lenses and NOT vision acuity with use of bioptics.)
Optometrist's/Ophthalmologists' Report of Vision Impairment
V3 (Optometrists's or Ophthalmologist's Report revised 2015)
Dear Licensed Optometrist/Ophthalmologist:
The patient before you is applying for a waiver from vision-related medical criteria* in order to operate a school bus or
Type III school bus within the state. We are asking your cooperation to examine this patient in accordance with this
criteria, which is required by state law and administrative rule. All criteria below must be addressed. Please certify
that you can complete this report by placing your signature and today's date at the bottom.
*Criteria is stipulated in Code of Federal Regulations, title 49, section 391.41, paragraph (b) (10) and Minnesota
Rules, section 7414.1200.
The patient's visual acuity is at least 20/40 (Snellen), corrected or uncorrected, in the better eye.
Patient Name (please print)
2)
The applicant's field of vision is no less than 120 degrees in one or both eyes together as
demonstrated on a Goldman perimeter, using an Ille target or equivalent field test that uses an
automated perimeter.
3)
The applicant recognizes the colors of red, green, and amber in traffic signals in an actual field
test, if he or she fails a color screening test or comparable color contrast sensitivity test.
4)
In my opinion, the patient can safely perform the normal required school bus or Type III school bus
driver operations.
5)
Two years from date of last physical
Other (as determined by physical).
6) The length of time that the vision waiver is valid (check one):
Examination Date (mm/dd/yy)
Physician Signature
Date (mm/dd/yy)
1) Please identify, and define, the visual deficiency.
Patient's Driver's License Number
X
- -
- -
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
Print this completed form and submit to Driver and Vehicle Services via: Email: [email protected], Fax: (651) 282-2110, or
Mail or Deliver in person: Driver and Vehicle Services, 445 Minnesota Street, St. Paul, Minnesota 55101-5180
Incomplete applications will be returned and may result in a waiver not being issued.
If you have questions or need additional information, please contact DVS at (651) 297-5029 or (651) 282-6555 (TTY)
Licensed Optometrist's/Ophthalmologist's Name (please print or type)
Office or Clinic Name Daytime Phone (include area code)
Please list waiver ending date:
Yes
Yes
Yes
Yes
No
No
No
No
