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| Question | Answer |
|---|---|
| Form Name | Mv 80L Form |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | New_York, WEARERS, mv 80l ny dmv, dmv eye test form mv 80l |
STATE OF NEW YORK
DEPARTMENT OF MOTOR VEHICLES
6 EMPIRE STATE PLAZA,ALBANY NY 12228
EYE TEST REPORT FOR MEDICAL REVIEW UNIT
MAIL TO:
Medical Review Unit, Rm. 337 New York State Department of Motor Vehicles 6 Empire State Plaza Albany NY 12228
(QUESTIONNAIRE FOR PERSONS WITH CORRECTED VISION OF LESS THAN 20/40
BUT NOT LESS THAN 20/70, OR TELESCOPIC LENS WEARERS)
INSTRUCTIONS:
This questionnaire must be completed by a physician, ophthalmologist or optometrist, and must be based on an
examination performed within 60 days.PLEASE RETURN THE COMPLETED ORIGINAL OF BOTH PAGES OF
THIS FORM TO THE MEDICAL REVIEW UNITAT THEADDRESS SHOWN IN THE BOXABOVE.
If this completed questionnaireandallrelatedstatementsare not returned to the Medical Review Unit (attheir
addressabove), your license may be suspended.YOU MUST HAVEAPPROVAL FROM THE MEDICAL REVIEW
UNIT BEFORE YOU CAN OBTAINAVALID LICENSE.ALL MEMBERS OF THE LOW VISION PROGRAMARE REQUIRED TO PROVIDEAN EVALUATION STATEMENT FROM THEIR EYE CARE PROVIDER EVERY
6 MONTHS OR ONCEAYEAR, DEPENDING UPON THE RECOMMENDATION OF THE EYE CARE PROVIDER.
MINIMUM STANDARD FOR INDIVIDUALS WITH CORRECTED VISION OF LESS THAN 20/40, BUT NOT LESS THAN 20/70:
Horizontal, binocular field of vision must be no less than 140 degrees.
MINIMUM STANDARD FOR TELESCOPIC LENS WEARERS:
Must have been fitted with, trained to use, and used telescopic lenses for at least 60 days prior to filing this form.
For a
Visual acuity (Snellen Method) through telescopic portion in either or both eyes must be NO LESS THAN20/40
Visual acuity (Snellen Method) through carrier lens in either or both eyes must be NO LESS THAN 20/100
Total horizontal, binocular field of vision (no field expanders) must be NO LESS THAN 140 DEGREES
Must pass road test if he/she has not taken a road test while wearing his/her telescopic lenses
Eligible for a Class D or DJ driver license only
Ineligible for a commercial driver license (CDL), a motorcycle license or a moped license.
PATIENT — COMPLETE THIS SECTION
PleasePrintorType
Name __________________________________________________________________________________________________
(Last)(First)(M.I.)
Address ________________________________________________________________________________________________
(Number and Street) |
(Apt. No.) |
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____________________________________________________________________________________________________________ |
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(City) |
(State) |
(Zip Code) |
NewYork State Client ID # ______________________ |
Date of Birth__________________ |
o Male o Female |
www.dmv.ny.gov |
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PRACTITIONER — COMPLETE THIS SECTION
Patient’s Name____________________________________________________________________ Date of Birth ____________________
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(Last) |
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(First) |
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(Month/Day/Year) |
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Date of Examination ____________________ (must be within 60 days) |
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Check One: oInitial Evaluation |
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(Month/Day/Year) |
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1. |
VisualAcuity(SnellenMethod) |
NOTE:Pleasechecktheappropriateboxtoidentifyhowvisualacuitywasachieved,thengivethevisualacuity. |
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oWith corrective lenses |
Right eye 20/______and/or left eye 20/______ |
Both 20/______ |
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oWithout corrective lenses |
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oWith telescopic lenses only |
Through telescopic lenses right eye 20/______and/or left eye 20/______ |
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Through carrier lenses right eye 20/______and/or left eye 20/______ |
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2. |
If telescopic lenses are used, on what date did patient receive them? |
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3. |
Does the patient meet or exceed the minimum acceptable horizontal, binocular field of vision of140 degrees? oYes |
oNo |
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NOTE:The test object size for determining horizontal, binocular field of vision must be either a white 3 mm size test object at a |
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meter distance, or a white 6mm size test object at a one meter distance, or the equivalentangular size for any test distance. |
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4. |
Iftelescopiclenses,didthepatientachievehis/herhorizontal,binocularfieldofvisionwiththeuseoffieldexpanders? |
oYes |
oNo |
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5.What medical condition(s) caused the present loss of the patient’s visual acuity?_________________________________________________
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_________________________________________________________________________________________________________________ |
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6. |
Patient should be |
. . . . . . . . . . . . . . . . . . . . . |
. .. . . . . . |
. . . . . . . . . o 6 Months |
oYear |
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7. |
Is this condition stable at this time? |
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. . . . . . . . . o Yes |
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oNo |
8. |
Check restriction(s) you recommend: oDay Driving Only |
oNo LimitedAccess Roads |
oNone |
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9. |
In your opinion, would the patient’s condition interfere with the safe operation of a motor vehicle?. . . |
. . . . . . . . . o Yes |
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oNo |
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If “Yes”, please explain in the space provided, or attach an explanation on your letterhead_________________________________________ |
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________________________________________________________________________________________________________________ |
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The above information is true, complete and best reflects my professional judgement. |
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__________________________________________________________________ |
_________________________________ |
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(Practitioner’s Signature) |
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(Date) |
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____________________________________________________________________ |
_________________________________ |
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(Practitioner’s Name — pleaseprint) |
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(Certificate or License Number) |
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____________________________________________________________________ (_____)___________________________
(Address) |
(Telephone Number) |
TELESCOPIC LENS WEARERS MUST COMPLETE THIS CERTIFICATION ONLY
I certify that I have successfully completed the minimum training requirements for telescopic lens wearers as outlined in Part 5 of the Commissioner’s Regulations, and that I received the training from:
_________________________________________________________________________ (_____)_____________________
(Name of Trainer)(Telephone Number)
_______________________________________________________________________________________________________
(Address of Trainer)
___________________________________________________________________ |
_________________________________ |
(Signature of Patient) |
(Date Training Completed) |
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