Form 412 Nc PDF Details

The South Carolina Department of Motor Vehicles Report of Vision Screening, known as Form 412-NC, plays a crucial role in ensuring the safety of drivers by establishing minimum vision requirements for non-commercial beginner permits or driver's licenses. This form, which is valid for 12 months from the date of the vision screening, must be filled out precisely, as any alterations or erasures render it void. It requires detailed information from the applicant, including personal identification and a signature, confirming their understanding of the test's significance. Critical to this process is the involvement of a licensed eye care professional, who assesses the applicant's vision to determine if it meets the state's standards without the aid of telescopic lenses or other attachments. The vision standards dictate acceptable acuity levels either with or without corrective lenses, emphasizing the importance of accurate vision screening for driving safety. To avoid any restrictions, applicants might be required to wear corrective lenses, and in some cases, limitations such as daylight driving only might be recommended. The form also addresses permanent sight impairments and suggests a timeline for rechecks to ensure ongoing visual fitness for driving. With detailed instructions for both the applicant and the eye care professional, the 412-NC form is a key document in the certification process, underscoring the collective responsibility towards maintaining safe driving conditions on South Carolina’s roads.

QuestionAnswer
Form NameForm 412 Nc
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namessc dmv eye exam form, what is an eye exam receipt number, eye exam receipt number dmv, eye exam receipt number sc

Form Preview Example

South Carolina Department of Motor Vehicles

Report of Vision Screening for

Non-Commercial Beginner Permits or Driver’s Licenses

412-NC

(REV. 11/12)

FORM IS ONLY VALID FOR 12 MONTHS FROM DATE OF VISION SCREENING

 

*****

This form is void if there are any alterations or erasures on it. *****

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s Name

 

 

 

 

Date of Birth

Driver’s License Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s Address

 

 

 

City

 

 

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s Signature

 

 

 

 

Date

 

 

Telephone Number

 

 

THIS SECTION IS TO BE COMPLETED BY A LICENSED EYE CARE PROFESSIONAL

***** Do not return this form to an applicant requiring corrective lenses until new lenses are fitted *****

Applicants must meet the minimum acceptable vision requirements, without the use of a telescopic lens or other attachment, provided below to obtain and maintain a South Carolina non-commercial driver’s license or beginner’s permit.

The South Carolina Department of Motor Vehicles’

minimum visual acuity requirements, with or without corrective lenses,

are as follows:

20/70 or better in at least one eye; OR

If applicant’s weaker eye is worse than 20/200, the stronger eye must read 20/40 or better; OR

Worse than 20/70 in each eye but 20/70 or better with both eyes together. This reading is only acceptable if accompanied by a statement from the eye care professional that no further improvement in vision can be made.

Distant Vision Only

Right

Left

Both

Eye

Eye

Eyes

 

 

Without Corrective Lens

 

20/

20/

20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

With Corrective Lens

 

20/

20/

20/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Prescription

 

20/

20/

20/

 

 

 

 

 

 

 

 

 

1. DOES THE APPLICANT’S VISION MEET THE ABOVE STANDARDS TO OPERATE A MOTOR VEHICLE?…… YES

NO

SECTION A – DRIVING RESTRICTIONS

2.Is a corrective lens, such as a conventional type spectacle or a contact lens, needed to operate a motor vehicle? ..................

3.Is the applicant’s vision worse than 20/200 in one eye? .............................................................................................................

4.Should the applicant be restricted to daylight driving only? ……………......................................................................................

Yes Yes

Yes

No

No

No

SECTION B – PERMANENT SIGHT IMPAIRMENT

5. a) Does the applicant have a permanent sight impairment?

Yes

No

b) If yes, which eye? …………………………………………………………………………………………………….………….……...

Right

Left

SECTION C – RECHECK VISUAL FITNESS

6.Indicate when the applicant’s eyes should be rechecked to determine visual fitness to operate a motor vehicle.

 

 

in 6 months

in 1 year

in 2 years

in 5 years

Other (Comments)

Comments:

 

 

 

 

 

 

 

I,

 

Professional No.

 

being licensed to practice

 

 

Printed Name of Eye Care Professional

 

 

 

 

 

 

 

 

 

in the state of

 

 

 

, certify that

I have performed a vision screening of the eyes of the above named person. This is a true record of this screening and the applicant met the visual acuity standards without the use of a telescopic lens or other attachment. I further certify that I have answered all of the questions above and that he or she signed in my presence.

Signature of Eye Care Professional

 

Screening Date

Telephone Number

 

 

 

 

 

 

 

 

 

Business Address

 

City

 

 

State

Zip Code

DMV USE ONLY

I verified that the applicant is not applying for a CDL.

Date

DMV Employee Name

Office #

South Carolina Department of Motor Vehicles

Report of Vision Screening for

Non-Commercial Beginner Permits or Driver’s Licenses

412-NC

(REV. 11/12)

INSTRUCTIONS TO APPLICANT OR DRIVER

The simple eye test given by the Department of Motor Vehicles (DMV) determines if an applicant may have 20/40 vision or better. If unable to pass DMV’s vision screening you must have your eyes screened by an eye care professional to determine if your eyes meet the Department’s vision screening requirements. Therefore, you are being asked to have

your eyes screened by an eye care professional to determine if your sight can be improved by glasses or treatments. If glasses will make you a safer driver, your license will permit you to drive only while wearing them.

Please do not ask the Department of Motor Vehicles to recommend an eye care professional as they are forbidden to do so.

If you have any questions about how well you must be able to see to be granted the privilege of driving on the streets and highways of South Carolina, the Department personnel will be glad to answer them.

EXPLANATION FOR EYE CARE PROFESSIONAL

All applicants for licenses and some drivers whose records cast doubt on their ability to drive safely are given simple vision tests by Department personnel, but when more accurate measurements are needed, when an improvement in vision would add to safety, or when unusual eye defects are apparent, the person is asked to visit an eye care professional. A report from such an eye care professional is particularly valuable if the fitness of a driver is questioned in court following an accident. In some cases, a screening by more than one eye care professional is requested.

You must provide the reading results and truthfully answer all of the questions. The individual must meet the visual acuity standards without the use of a telescopic lens or other attachment. If the case is a peculiar one, any additional comments which you may have would be appreciated. Use a separate sheet if needed and attach it to the form.

Kindly sign this report and give your professional number. For proper identification, have the person screened to sign the report in your presence.

No recommendations or suggestions as to which eye care professional to visit are given by Department personnel. Only reports from licensed eye care professional can be accepted. The eye care professional assumes no responsibility in making this report other than that of truthfully representing the facts.

MAIL MEDICAL INFORMATION TO:

Department of Motor Vehicles

Driver Improvement Office

P.O. Box 1498

Blythewood, S.C. 29016-0016

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sc eye exam receipt number conclusion process described (stage 1)

2. The next stage is usually to submit the next few blank fields: DOES THE APPLICANTS VISION MEET, Yes, Yes, Yes, Right, Yes, in months, in year, in years, in years, Other Comments, Comments, No No No, No Left, and Printed Name of Eye Care.

sc eye exam receipt number completion process shown (part 2)

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Stage # 3 for filling in sc eye exam receipt number

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