Illinois Vision Specialist Report Form – Fill Out and Use This PDF

This Side of Form to be Completed for Prescription Mounted Telescopic Lens Wearers ONLY

Sections I, II, V, VI, VII and the following sections must be completed for prescription spectacle mounted telescopic lens. Applicants who qualify to drive with the use of a Prescription Telescopic Lens Arrangement shall be restricted to driving during daylight hours only and shall be eligible for a Class "D" driver's license only.

VIII. ACUITY SECTION:
	Minimum Visual Screening Standards—Acuity	Vision Specialist Examination Certification
	Prescription Spectacle Mounted Telescopic Lens(es)
		Acuity	Both	Right	Left
–	Telescopic lens(es) may not exceed 3X wide angle, or 2.2X standard	Through carrier lenses	20/	20/	20/
–	Central acuity through the telescopic lens must be 20/40 or better	Through telescopic lenses	20/	20/	20/
–	Central acuity through the carrier must be 20/100 or better	Without correction	20/	20/	20/

–Left and right outside rearview mirror = to or greater than 20/100 (monocular vision through telescopic lenses)

IX. PERIPHERAL SECTION:

Minimum Visual Screening Standards—Peripheral

Prescription Spectacle Mounted Telescopic Lens(es)

–Peripheral 140° binocular or monocular 70° temporal and 35° nasal with the prescription spectacle mounted telescopic lens(es) in place and without the use of field enhancers

Vision Specialist Examination Certification

Left Eye	Right Eye	Total Field of
Temporal Reading	Temporal Reading	Vision*
	+	=
______________ °	______________ °	______________ °
		(140° or greater – qualification with no restrictions.
		If 139° or less see below)

*If the total field of vision above equals less than 140° , the applicant may still be able to qualify for a driver's license with restrictions. Screen each eye individually by finding a temporal and a nasal reading. At least one of the eyes must have a minimum temporal reading of 70° and a minimum nasal reading of 35° for a total of 105° in order to qualify with a restriction of both a left and a right outside rearview mirror. If neither eye has at least 70° temporal and 35° nasal, the applicant is not qualified to be licensed to drive in Illinois.

Complete only if received less than 140° total field of vision above:
	Left Eye					Right Eye
Temporal	Nasal	Total	Temporal			Nasal	Total
_________ °	+	=	_________ °		+	_________ °	=
	_________ °	_________ °					_________ °
X.
– Date the applicant received the telescopic lens arrangement				____________________
– Power of the telescopic lens arrangement				____________________
– Is the patient's condition stable?				❒Yes	❒ No
– In your professional opinion, is there any indication that the applicant				❒Yes	❒ No
may not be capable of safely operating a motor vehicle?
– Indicate any additional comments or restrictions:
XI.
Has the patient successfully completed all the following requirements:				❒ Yes		❒ No

•The patient has been fitted for a prescription spectacle mounted telescopic lens arrangement and has had this arrangement in his/her possession for at least 60 days prior to the application date.

•The patient has clinically demonstrated the ability to locate stationary objects within the telescopic field by aligning the object directly below the telescopic lens and moving the head down and the eyes up simultaneously.

•The patient has clinically demonstrated the ability to locate a moving object in a large field of vision by anticipating future movement, so that by moving the head and eyes in a coordinated fashion, he/she is able to locate the moving object within the telescopic field.

•The patient has clinically demonstrated the ability to remember what has been observed after a brief exposure, with the duration of the exposure progressively diminished to simulate reduced observation time while driving.

•The patient has experienced levels of illumination which may be encountered during inclement weather or when driving from daylight into areas of shadow or artificial light and the patient has clinically demonstrated the ability to successfully adjust to such changes.

•The patient has experienced walking and riding as a passenger in a motor vehicle so that he/she has practical experience of motion while objects are changing position.