Tennessee Department of Safety and Homeland Security Vision Examination Form SF-0257 at a glance
What it is: Tennessee Department of Safety and Homeland Security vision examination form.
Who signs: SIGN: Signature of Examining Doctor, DATE, Medical License Number, STATE. SIGN: Signature of Person Receiving Eye Examination, DATE.
A possible vision impairment would affect your ability to safely operate a motor vehicle. You are being asked to have your vision checked by a licensed eye care Doctor of Optometry or Doctor of Ophthalmology to determine whether your vision can be improved by eye glasses or eye treatment.
This report can only be accepted from a licensed Doctor of Optometry or Doctor of Ophthalmology.
A filled-in Tennessee Department of Safety and Homeland Security Vision Examination Form SF-0257 example: an eye doctor records a driver's vision
How to fill out Tennessee Department of Safety and Homeland Security Vision Examination Form SF-0257, box by box
Full Name of Person Examined
Full Name of Person Examined: First, Middle and Last Name. Street Address, City, State and Zip Code.
Acuity
ACUITY: RIGHT EYE, LEFT EYE and BOTH EYES, each 20/, WITH PRESENT GLASSES (IF ANY), WITHOUT GLASSES and WITH BEST POSSIBLE CORRECTION.
Color test and total angle
TOTAL ANGLE. COLOR TEST.
Questions 1 to 6
1. Are glasses needed for distant vision? Are they being prescribed or fitted?
2. Describe any irregularities such as: Double vision, poor night vision, eye injury, eye disease, poor near vision, etc.
3. Will eye glasses improve conditions described in Question 2?
4. Will other treatments improve the described conditions for the eyes?
5. Is the person named in this report currently undergoing the recommend treatment to improve vision?
Certification of ophthamologist or optometrist
Upon completion of your eye examination of the driver applicant, please completely fill out this form and certification.
I, being licensed to practice in the specialty of eye care, in the State of, certify I have personally examined the eyes.
A true record of this examination appears on this report and he or she signed in my presence.
SIGN: Signature of Examining Doctor, DATE, Medical License Number, STATE.
Office Address, City, STATE, ZIP CODE and Office Telephone Number.
Patient sign this form in your presence
Please have patient sign this form in your presence.
More rules for Tennessee Department of Safety and Homeland Security Vision Examination Form SF-0257
All applicants for a driver license as well as drivers whose record cast doubt on their ability to drive safely, are given vision screenings by the Driver License Examiners. When this screening indicates that a vision examination is needed by an eye care professional, the person is asked to visit a vision specialist.
No recommendations or suggestions are given by the Tennessee Department of Safety and Homeland Security Driver License Examiners as to which eye specialist to visit.
If you have any questions about how well you must be able to see to drive on the streets and highways of Tennessee, the Driver's License Examiner will be glad to assist you. Driver License Examiners are prohibited from referring you to or recommending the name of an eye specialist.
If your situation is different
After the eye examination
When you return to the Driver Service Center after your eye examination, you must bring this completed form by your eye doctor, along with any new eye glasses or corrective lenses.
Sources
[1] Tennessee Department of Safety and Homeland Security Vision Examination Form SF-0257 (Rev. 1/12) (the Official source link on this page).