Cdl Vision Screening Certificate -Registry Of Motor Vehicles
ADVERTISEMENT
1
2CDL
VISION SCREENING CERTIFICATE
Applicants for class A, B, or C learner’s permits or licenses may use this form. This form must be completed by an
ophthalmologist or by an optometrist who is licensed to practice in the Commonwealth of Massachusetts.
Minimum required visual standards for CDL as described by Federal Motor Carrier Safety Administration
49 CFR §391.41 Physical qualifications for drivers
“Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected
to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or
without corrective lenses, field of vision of at least 70º in the horizontal meridian in each eye, and the ability to recognize the
colors of traffic signals and devices showing standard red, green, and amber;” Monocular drivers are not qualified.
Type or Print
Name of Applicant
License number
I hereby authorize the ophthalmologist or optometrist completing this form to discuss its content with representatives of the
Registry of Motor Vehicles.
Applicant's Signature
Applicant's Phone
Date
(
)
*************************************************************************************************************
VISION SCREENING DATA
1.
VISUAL ACUITY (Snellen)
WITHOUT RX
WITH RX
Right Eye (OD)
20/
20/
Left Eye (OS)
20/
20/
Both Eyes (OU)
20/
20/
DO NOT
+
-
,
(“CF”)
.
USE QUALIFIERS SUCH AS
OR
SYMBOLS
OR THE COUNTING FINGERS
DESIGNATION TO INDICATE VISUAL ACUITY
2.
TOTAL HORIZONTAL VISUAL FIELD - Both Eyes Combined:
(Record in Degrees).
**Suggested Target size to be used: 10mm.
3.
Are glasses and/or contact lenses needed for driving?
YES
NO
(Check One)
(
“YES”,
1
“WITH RX”)
IF
QUESTION
SHOULD INDICATE VISUAL ACUITY
4.
Is the applicant's vision characterized by:
Irresolvable Diplopia?
YES
NO
(Check One)
NOTE: T
“NO” MUST
4.
O OBTAIN A LICENSE
BE CHECKED TO QUESTION
T21848-1010
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal