Form Dds Ve1 – Fill Out and Use This PDF

CDL Vision Exemption Form

A photo copy of both sides of your current driver’s license (CDL or non‐CDL)

If address on application is different than the address on your driver’s license you must indicate on the bottom of page 2 why the address on the license is different than the address on the application

Provide documentation that you have been examined by an ophthalmologist or an optometrist in the last 3 months. A CDL Vision Report is included as part of this packet for your convenience.

DDS will obtain and review your MVR (driving record) for three years. You must have a Georgia license to apply for the CDL Vision Exemption. Your application will only be considered if the driving record:

O Contains no suspensions, withdrawals, or revocations of your driver’s license for the operation of any motor vehicle (including your personal vehicle);

O Contains no involvement in an accident for which you contributed or received a citation for a moving traffic violation;

O Contains no convictions for a disqualifying offense, as defined in 49CFR383.51(b)(2), or more than one serious traffic violation, as defined in 49 CFR 383.5, while driving a CMV during the 3 year period, which disqualified or should have disqualified you in accordance with the driver qualification provisions of 49 CFR 383.51;

O Contains no more than two convictions for any other moving traffic violations

Upon receipt of current and complete information, an individual evaluation for an exemption from the Federal vision standard will be conducted, and you will be notified of the results. If you do not provide this information, your application will be rejected. An exemption may be issued for a maximum of two (2) years, but may be renewed at the discretion of the State (Department of Driver Services). Any exemption issued in response to your application is valid for operations only within the State of Georgia. It does not exempt you from having to meet all other physical qualifications, nor does it exempt you from the physical qualifications from any bordering jurisdiction(s).

Part 5: Self Certification

“I acknowledge that I must be otherwise qualified under 49 CFR 391.41(b)(1‐13) or hold another valid medical exemption before I can legally operate a commercial motor vehicle.”

_________________________________________________	____________________________________
Signature of Applicant	Date

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CDL Vision Exemption Form

GEORGIA DEPARTMENT OF DRIVER SERVICES

CDL VISION REPORT

(Must be completed by Optometrist or Ophthalmologist)

APPLICANT DRIVERS LICENSE NO. ____________________ EXAMINATION DATE: _______________

APPLICANT’S FULL NAME: _______________________________________________________________

STREET ADDRESS: ______________________________________________________________________

CITY: _____________________________________ STATE: ________ DOB: ________________________

TO EXAMINING DOCTOR:

Please complete this CDL Vision Report in its entirety. Please leave blank any spaces for tests on which you have made no examination. If the case is peculiar, additional comments on a separate sheet would be appreciated.

This section must be completed.

REPORT ON VISUAL ACUITY EXAMINATION

DISTANT VISION ONLY	RIGHT EYE	LEFT EYE	BOTH EYES
WITHOUT GLASSES	20/_______	20/_______	20/_______
WITH PRESENT GLASSES	20/_______	20/_______	20/_______
WITH NEW PRESCRIPTION	20/_______	20/_______	20/_______
WITH BIOPTIC PRESCRIPTION	20/_______	20/_______	20/_______

IF POSSIBLE MEASURE ABOVE AT 20 FEET, IF NOT STATE DISTANCE USED: _______________________

Check here if correction is achieved with other than conventional lenses (bioptics). If box is checked a detailed report must be attached.

This section must be completed. Cannot contain words such as ‘full’ or ‘normal’

FIELDS‐HORIZONTAL MERIDIAN: MUST BE MEASURED IN DEGREES

RIGHT: ________DEGREES	LEFT:________DEGREES				TOTAL: ________DEGREES
EVIDENCE OF SUPPRESSION: _____________________________________________________________
COORDINATION AT 20 FEET	EXO______	ESO______		RT.H______ LF.H______
FUSION‐DISTANCE:	EXCELLENT	GOOD	POOR	NONE	TEST USED:________________
FUSION‐NEAR:	EXCELLENT	GOOD	POOR	NONE	TEST USED: ________________
DEPTH PERCEPTION:	EXCELLENT	GOOD	POOR	NONE	TEST USED: ________________

	This section must be completed.
	COLOR VISION (ability to distinguish red/green/amber): NORMAL DEFICIENT FAILED		TEST USED: __________
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CDL Vision Exemption Form

Please identify and define the nature of the vision deficiency, including how long the patient has had the vision deficiency: _______________________________________________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Has the vision deficiency remained stable for the previous five years:

Yes

No

Are corrective lenses needed for distant vision? ______ For near vision? ______ Is there any double

vision: ______ If so, is it corrected with glasses or other treatment? _____________________________

Any evidence of eye disease or injury? ______ If so, describe: __________________________________

_____________________________________________________________________________________

_____________________________________________________________________________________

Can this be corrected or compensated for? __________________________________________________

Any difficulty in seeing in dim light or at night? _______________________________________________

Examining professional MUST answer this question:

In your opinion, does this person have sufficient vision to operate a commercial motor vehicle safely?

_______ If, yes should there be any restrictions imposed? ____________ If so what restrictions?

_____________________________________________________________________________________

COMMENTS: __________________________________________________________________________

CERTIFICATION OF VISION SPECIALIST

I, __________________________________________________________________ being licensed to

practice in Georgia, certify that I have personally examined the vision of the above named person, that a true record of this examination appears on this report and that he or she signed this form in my presence.

Signature of examining doctor	State license #		Date
Printed name of examining doctor	Office telephone number (include area code)
Business Street Address	City	State	Zip Code

IMPORTANT: For proper identification, please ensure that you have obtained picture identification of the person being examined and that that is the person identified on this vision report. Have the person whom you have examined sign the report in your presence.

Signature of applicant (person having eye exam)

Date

		PHYSICIAN MUST MAIL ORIGINAL COMPLETED FORM (ALL 4 PAGES) TO:
		DEPARTMENT OF DRIVER SERVICES
		ATTN: CDL Compliance
		P.O. Box 833
		Macon, GA 31201
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