Form 412 Nc – Fill Out and Use This PDF

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.

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

NO

SECTION A – DRIVING RESTRICTIONS

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 #

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