Vision Certification Form (DMV/School/Work)

Patient Name: [Patient full name]

Date of Birth: [YYYY-MM-DD]

Date of Examination: [YYYY-MM-DD]

Date Form Completed: [YYYY-MM-DD]

Certification Request

Requesting entity: [DMV / school / employer / other / Not specified]
Form name/identifier: [Form name or ID, or "Not provided"]
Reason for request: [new application / renewal / restriction removal / accommodation / return-to-work / other]
Basis of findings: [today's examination / review of prior records / both] (If prior records used, specify source and date.)
Authorization: [Patient authorizes release to the specified recipient / Authorization on file dated [date]]

Testing Methodology

[Test distance] using [chart type]. (If near acuity measured, include near test format and working distance.) Reliability: [no limiting factors / limited by poor cooperation / language barrier / cognitive impairment / habitual correction not available / other]. (If results are unreliable, state: "Results are of limited reliability; certification decision should not rely on these results alone.")

Visual Acuity

(Use exact notation such as 20/40 or 0.3 logMAR. For vision below chart threshold, use CF at [distance], HM, LP, or NLP.)

Distance Visual Acuity

• OD (Right): Uncorrected [VA]; with habitual correction [VA]; best-corrected [VA] (if refraction performed); pinhole [VA] (if used)
• OS (Left): Uncorrected [VA]; with habitual correction [VA]; best-corrected [VA] (if refraction performed); pinhole [VA] (if used)
• OU (Both): With habitual correction [VA]; best-corrected [VA] (if measured)

Corrective device used: [none / glasses / contact lenses / specialty device] (If specialty device, specify type.)
Correction required to achieve documented acuity: [Yes / No] (If yes, state: "Meets acuity requirement only with corrective lenses.")

Near Visual Acuity

(Include only when relevant to the certification request.)

• Testing format: [Jaeger / Snellen near / continuous text / other] at [working distance]
• OD: Without correction [VA]; with correction [VA]
• OS: Without correction [VA]; with correction [VA]
• OU: With correction [VA] (if measured)

Visual Fields

Method: [Confrontation / Formal automated perimetry / Not performed]

• (For confrontation) Findings: [normal / abnormal with description of defects]
• (For formal perimetry) Test type: [test name and parameters]; Date: [date]; Monocular field extent: OD [horizontal]° × [vertical]°, OS [horizontal]° × [vertical]°; Binocular field extent: [horizontal]° × [vertical]° (if required by form)
• (Provide numeric degrees; do not use "full" or "normal" alone when the receiving entity requires quantified values.)

Color Vision

Ability to recognize red, green, and amber signals: [Yes / No / Indeterminate / Not tested]
Test method: [Ishihara plates / HRR / functional signal recognition / other / Not tested]

Binocular Function

Diplopia: [Absent / Present]

(If present, specify: [monocular / binocular], [constant / intermittent], provoking conditions [gaze position / distance / fatigue / other]. Note any ocular alignment or motility issues affecting function.)

Additional Functional Assessment

(Include only if testing was performed or patient reports significant functional limitations.)

• Objective measures: [Contrast sensitivity, glare testing, or night vision assessment with method and result] (List only tests performed.)
• Patient-reported symptoms: [Symptoms attributed to patient, e.g., "Patient reports difficulty with night driving and glare sensitivity."]

Relevant Diagnoses

(Include only diagnoses that explain measured limitations or are required for certification. If none, state: "No ocular conditions affecting measured visual function.")

• [Diagnosis] — [stable / progressing] — Treatment: [current treatment] — Functional impact: [plain-language link to measured deficits]

Recommendations and Restrictions

Clinical recommendations: [Specific recommendations tied to deficits, e.g., corrective lenses required, preferential seating, large print materials, task lighting, glare reduction, extended time for visual tasks, safety eyewear]

Driving or work restrictions (clinical advisement): [e.g., requires corrective lenses; recommend daytime driving only based on documented glare disability] (Distinguish clinical recommendations from agency determinations. Do not state "meets [agency] standard" unless the specific standard is identified and all required testing was performed.)

Follow-up: [Not indicated / Re-evaluate in [timeframe] due to [reason]]

Clinician Attestation

I certify that I performed or directly supervised the vision evaluation on the above-listed examination date and that the findings documented herein are true and accurate to the best of my knowledge.

Printed name and credentials: [Name], [MD / DO / OD / PA / NP]
License number and state: [License number], [State]
Clinic: [Clinic name, address, phone]
Signature: [Signature]
Date signed: [YYYY-MM-DD]

(If form is generated before signature, mark prominently: "PENDING SIGNATURE—NOT VALID FOR RELEASE UNTIL SIGNED." Remove this statement once signed.)