Fillable Printable Dl Vision Report
Fillable Printable Dl Vision Report
Dl Vision Report
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
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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
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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 SpeedmphLimit tomiles from homeNo 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?
NOYES
Anticipated date when treatment will be complete:
Has treatment been scheduled?
NOYES
Vision Examiner's Name:
Office
Address
:
Vision Examiner's Signature
Date
License
Number
:
Phone Number:
StreetCityStateZip 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 years3 years2 years1 year6 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.)
