Form Dl-102 - Report Of Eye Examination Template
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1DL-102 (4-12)
REPORT OF EYE EXAMINATION
To be completed by an optometrist, ophthalmologist, physician
assistant, certified registered nurse practitioner, or licensed
physician with equipment to properly evaluate vision
Bureau of Driver Licensing
P.O. Box 68682
Harrisburg, PA 17106-8682
PLEASE TYPE OR PRINT IN BLUE OR BLACK INK ALL INFORMATION
(717) 787-9662
THIS FORM APPROVED BY THE MEDICAL ADVISORY BOARD 4/13/12
Provider: For more information relating to Medical Reporting, visit
PATIENT INFORMATION
Are you a CDL driver? ❏ YES ❏ NO
DRIVER’S LICENSE NO.
LAST NAME(S)
JR. ETC
FIRST NAME
HEIGHT SEX EYE COLOR DATE OF BIRTH TELEPHONE NUMBER E-MAIL ADDRESS: (if applicable)
FEET INCHES
MONTH
DAY
YEAR
STREET
P.O. Box number may be used in addition to the actual address,
CITY
STATE ZIP CODE
ADDRESS: but cannot be used as the only address.
REGULAR DRIVER (CLASS A, B, C & M)
UNCORRECTED
1. Please indicate individual's visual acuity by marking the appropriate box:
R 20/
❑
A. Combined vision is 20/40 or better. . . .With Correction
❑
W/O Correction
❑
L 20/
❑
B. Combined vision is poorer than 20/40 but has been corrected to 20/60 or better.
B 20/
C. Combined vision is poorer than 20/60 but has been corrected to at least 20/70.
CORRECTED
❑
R 20/
a) Do you consider this person visually capable to drive?. . . . Yes
No
❑
❑
L 20/
D. Combined vision is poorer than 20/70 and not correctable to 20/70.
❑
B 20/
CHECK ONE: YES NO
2. Is individual's combined field of vision at least 120° in the horizontal meridian,
❏ ❏
excepting the normal blind spots? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
3. Does individual have better than 20/100 vision in each eye with correction? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
4. Must individual wear corrective lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
5. Is correction obtained through telescopic lenses? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
6. Does this individual's condition warrant monitoring by the Department? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If so, how often? __________________________________________________________________________
YES NO
SCHOOL BUS DRIVERS (S ENDORSEMENT):
1. Individual has distant visual acuity of at least 20/40 in the BETTER eye without corrective lenses
❏ ❏
or visual acuity corrected to 20/40 or better? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2. Individual has at least 20/50 in the POORER eye without corrective lenses or visual acuity
❏ ❏
corrected to 20/50 or better? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
3. Individual has distant binocular acuity of at least 20/40 in both eyes with or without corrective lenses? . . . . . . . . .
4. Is individual's combined field of vision at least 160
in the horizontal meridian, excepting the
0
❏ ❏
normal blind spots? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Individual has the ability to determine colors used in traffic signals and devices showing
❏ ❏
standard red, green or amber. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
6. Individual must wear corrective lenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
❏ ❏
7. Has the patient had an annual dilated eye exam? If yes, date of last exam:_______________________________
❏ ❏
8. Does this individual's condition warrant monitoring by the Department? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If so, how often? __________________________________________________________________________
HEALTH CARE PROVIDER'S INFORMATION (Please print or type)
HEALTH CARE PROVIDER'S NAME
SPECIALTY HEALTH CARE PROVIDER'S LICENSE NUMBER
STREET ADDRESS
CITY STATE ZIP CODE
TELEPHONE NUMBER
FAX NUMBER
I hereby state that the facts above set forth are true and correct to the best of my knowledge, information and belief. I understand that the statements
made herein are made subject to the penalties of 18 Pa. C.S. § 4904 (relating to unsworn falsification to authorities) punishable by a fine up to $2,500
and/or imprisonment up to 1 year.
Health Care Provider's Signature
Date
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