Dmv Vision Test Illinois Form – Fill Out and Use This PDF

The DMV Vision Test Illinois form, officially recognized as the Vision Specialist Report by the Secretary of State, is a critical document designed to assess an individual's visual capabilities for obtaining or maintaining a driver's license in Illinois. Integral to ensuring road safety, this form requires thorough completion by a registered vision specialist following a detailed examination of the applicant's visual acuity and peripheral vision. Individuals in need of corrective lenses, especially those seeking to use prescription mounted telescopic lens arrangements, will find specific sections dedicated to their assessment, ensuring personalized attention to their unique needs. Ready to secure your driving privileges with clear vision? Click the button below to fill out your form.

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Dmv Vision Test Illinois Form PDF Details

The DMV Vision Test Illinois form serves as a crucial tool in assessing the visual abilities of individuals applying for a driver's license within the state. Secretary of State Jesse White oversees its administration, ensuring drivers meet necessary vision standards for safe vehicle operation. Including sections for applicant information and detailed instructions for vision specialists, this form encapsulates a comprehensive evaluation spanning acuity, peripheral vision, and potential use of telescopic lenses. Applicants failing to achieve the minimum vision standards are referred to a vision specialist, who then determines their eligibility for corrected or restricted driving privileges. Notably, the form underscores a unique segment dedicated to those requiring prescription-mounted telescopic lenses, outlining stringent requirements for acuity and peripheral vision. It highlights the importance of an accurate and thorough examination by certified vision specialists, who must not only assess but also certify the vision capabilities of each applicant. Additionally, the form includes sections for comments and recommendations, facilitating a tailored approach to address individual visual impairments. This report ultimately plays a pivotal role in maintaining road safety by ensuring that drivers possess adequate vision, either naturally or through correction, to navigate Illinois' roadways safely.

Question	Answer
Form Name	Dmv Vision Test Illinois Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	illinois dmv eye test, illinois drivers license vision test, illinois dmv vision test online covid, dmv eye test machine illinois

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						Secretary of State
I. APPLICANT INFORMATION							State of Illinois
		VISION SPECIALIST REPORT

Name	Last	First	Middle	Driver's License Number

Street Address					Birth Date			Sex
				Month	Day	Year		❒ M	❒ F
								❒ M	❒ F

City		County	ZIP Code	Driver Facility Control Number and Date:

II. INSTRUCTIONS TO VISION SPECIALIST

Applicants applying for an Illinois driver's license may be required to pass a vision screening. If the vision standards are not met, the applicant will be referred to a vision specialist. Driver Services employees do not recommend or suggest which registered vision specialist to contact.

Have the applicant sign and date this report in your presence. Place your signature and certificate number in Section VII. Comments may be entered in Section V. Sections VIII to XI (reverse side) must be completed for an applicant who desires to use a prescription mounted telescopic lens arrange- ment. READINGS WHICH INDICATE A PLUS (+) OR MINUS (–) ARE NOT ACCEPTABLE. (EXAMPLE: 20/40-1 OR 20/100+2)

If needed, a supplementary sheet, which has been signed and dated, may be attached to this report.

I authorize release of the report of this examination to the Secretary of State, Driver Services Department, Springfield, Illinois, for confidential use in my driver's record. This report shall remain valid for six months from the examination date shown below.

____________________________________________		_______________________________________________________
Applicant Signature		Telephone Number (Telescopic Lens Wearer Only)

III. ACUITY SECTION
Minimum Visual Screening Standards—Acuity			(For telescopic lens arrangements complete the report in Section VIII)
				Vision Specialist Examination Certification
Acuity: –	No restrictions = 20/40 (without corrective lenses)			Acuity	Both	Right	Left
–	Daylight driving only = 20/41 to 20/70		With correction		20/	20/	20/
	(with best correction binocular)
–	Failure = 20/71 or less (binocular)		Without correction		20/	20/	20/
–	Left and right outside rearview mirror = to or greater than 20/100 (monocular)

IV. PERIPHERAL SECTION
	Minimum Visual Screening Standards—Peripheral
Peripheral: –	Monocular = 70° temporal and 35° nasal	(For telescopic lens arrangements complete the report in Section VIII)
	(105° total field)	Vision Specialist Examination Certification
–	Binocular = 140° total temporal field	Left Eye		Right Eye		Total Field of
	Temporal Reading			Temporal Reading		Vision*
				+	=
	______________ °			______________ °		______________ °
						(140° or greater – qualification with no
						restrictions. If 139°	or less see below)

*If the total field of vision above equals less than 140° , the applicant may still be able to qualify for a driver's license with restrictions. Screen each eye individually by finding a temporal and a nasal reading. At least one of the eyes must have a minimum temporal reading of 70° and a minimum nasal reading of 35° for a total of 105° in order to qualify with a restriction of both a left and a right outside rearview mirror. If neither eye has at least 70° temporal and 35° nasal, the applicant is not qualified to be licensed to drive in Illinois.

Complete only if received less than 140° total field of vision above:

	Left Eye			Right Eye
Temporal	Nasal	Total	Temporal	Nasal	Total
	+	=		+	=
_________ °	_________ °	_________ °	_________ °	_________ °	_________ °

The specialist will please check all applicable items:

1.	____	Applicant should drive in daylight only.
2.	____	Applicant would not accept correction.
3.	____	Corrective lens(es) were accepted, checked and approved.
		Date: ___________________________

4. ____ Prescription spectacle mounted telescopic lens arrange-

ment. (See reverse.)

Comments:

VI.

Please check all applicable items:

1.	____	Annual exam
2.	____	Condition stable
3.	____	Condition deteriorating (please explain)
4.	____	Condition warrants monitoring (please explain)

5. ____ Other (please explain)

If #3, 4 or 5 is marked, please indicate diagnosis and your recommen- dation for re-examination in ____ 6 months ____ 12 months

____ Other

VII.

I certify that I have personally examined the eyes of the above-named individual and that a true record of my examination appears hereon.

Signature __________________________________________________	Certificate No. ______________________________________
Business Address ___________________________________________	Telephone Number __________________________________
Date of Examination _________________________________________	City/ZIP Code _____________________________________

JESSE WHITE • Secretary of State

DSD X-20.10

This Side of Form to be Completed for Prescription Mounted Telescopic Lens Wearers ONLY

Sections I, II, V, VI, VII and the following sections must be completed for prescription spectacle mounted telescopic lens. Applicants who qualify to drive with the use of a Prescription Telescopic Lens Arrangement shall be restricted to driving during daylight hours only and shall be eligible for a Class "D" driver's license only.

VIII. ACUITY SECTION:
	Minimum Visual Screening Standards—Acuity	Vision Specialist Examination Certification
	Prescription Spectacle Mounted Telescopic Lens(es)
		Acuity	Both	Right	Left
–	Telescopic lens(es) may not exceed 3X wide angle, or 2.2X standard	Through carrier lenses	20/	20/	20/
–	Central acuity through the telescopic lens must be 20/40 or better	Through telescopic lenses	20/	20/	20/
–	Central acuity through the carrier must be 20/100 or better	Without correction	20/	20/	20/

–Left and right outside rearview mirror = to or greater than 20/100 (monocular vision through telescopic lenses)

IX. PERIPHERAL SECTION:

Minimum Visual Screening Standards—Peripheral

Prescription Spectacle Mounted Telescopic Lens(es)

–Peripheral 140° binocular or monocular 70° temporal and 35° nasal with the prescription spectacle mounted telescopic lens(es) in place and without the use of field enhancers

Vision Specialist Examination Certification

Left Eye	Right Eye	Total Field of
Temporal Reading	Temporal Reading	Vision*
	+	=
______________ °	______________ °	______________ °
		(140° or greater – qualification with no restrictions.
		If 139° or less see below)

Complete only if received less than 140° total field of vision above:
	Left Eye			Right Eye
Temporal	Nasal	Total	Temporal	Nasal		Total
	+	=		+		=
_________ °	_________ °	_________ °	_________ °	_________ °		_________ °

X.
– Date the applicant received the telescopic lens arrangement			____________________
– Power of the telescopic lens arrangement			____________________
– Is the patient's condition stable?			❒Yes	❒ No
– In your professional opinion, is there any indication that the applicant			❒Yes	❒ No
may not be capable of safely operating a motor vehicle?			❒Yes	❒ No
– Indicate any additional comments or restrictions:

XI.
Has the patient successfully completed all the following requirements:				❒Yes	No❒

•The patient has been fitted for a prescription spectacle mounted telescopic lens arrangement and has had this arrangement in his/her possession for at least 60 days prior to the application date.

•The patient has clinically demonstrated the ability to locate stationary objects within the telescopic field by aligning the object directly below the telescopic lens and moving the head down and the eyes up simultaneously.

•The patient has clinically demonstrated the ability to locate a moving object in a large field of vision by anticipating future movement, so that by moving the head and eyes in a coordinated fashion, he/she is able to locate the moving object within the telescopic field.

•The patient has clinically demonstrated the ability to remember what has been observed after a brief exposure, with the duration of the exposure progressively diminished to simulate reduced observation time while driving.

•The patient has experienced levels of illumination which may be encountered during inclement weather or when driving from daylight into areas of shadow or artificial light and the patient has clinically demonstrated the ability to successfully adjust to such changes.

•The patient has experienced walking and riding as a passenger in a motor vehicle so that he/she has practical experience of motion while objects are changing position.

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