Fillable RMV - MAB102 Class D And M Vision Screening Certificate

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RMV - MAB102 Class D And M Vision Screening Certificate

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Class D and M Vision Screening Certificate
p.1 MAB102_0318
Applicants for a Class D or M learner’s permit or driver’s license may use this form. This form must be completed by an ophthalmologist
or by an optometrist who is licensed to practice in the Commonwealth of Massachusetts.
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
Massachusetts Driver’s License #
Phone #
Signature: __________________________ Date: _____________
With Bioptic Telescope
1. Visual Acuity (Snellen) Without RX With RX (Class D Licenses Only)
Right Eye (OD) 20/___ 20/___ 20/___ (through telescope)
Left Eye (OS) 20/___ 20/___ 20/___ (through carrier lens)
Both Eyes (OU) 20/___ 20/___ 20/___ (through other lens)
Do NOT use qualifiers such as + or – symbols, or the counting fingers (“CF”) designation to indicate visual acuity.
2. Total Horizontal Visual Field –
Both Eyes Combined: ___________ (Record in Degrees).
**Suggested Target size to be used: 10mm
3. Are glasses and/or contact lenses needed for driving? . ....................................................................................................................... Yes No
If yes, Question #1 should indicate visual acuity “With RX”
4. Are bioptic telescopic lenses needed for driving? .................................................................................................................................. Yes No
a) If yes, Question #1 should indicate visual acuity “With Bioptic Telescope” as well as “With RX”
b) If yes, the bioptic telescope:
Is Monocular? ........................................................................................................................................................................... Yes No
Is Fixed focus? ......................................................................................................................................................................... Yes No
Is NO greater than 3X? ............................................................................................................................................................ Yes No
Is Spectacle-mounted and an integral part of the lens? ............................................................................................................ Yes No
Does not occlude the line of sight or other eye? ....................................................................................................................... Yes No
NOTE: To obtain a license, “Yes” must be checked for ALL of the criteria in Question # 4b.
5. Is the applicant’s vision characterized by Unresolved Diplopia?. ........................................................................................................... Yes No
NOTE: To obtain a license, “No” must be checked in Question # 5.
6. Can the applicant distinguish red, green, and amber colors? ................................................................................................................ Yes No
NOTE: To obtain a license, “Yes” must be checked in Question # 6.
Listed below are the conditions, treatment, or medication plan which the applicant must follow in order to maintain the validity of my professional
opinion:
_______________________________________________________________________________________________________________________
A license is valid for five (5) years. Do you think that the applicant should be re-evaluated by the Registry during that time period? ........ Yes No
If “YES,” please complete:
“I recommend a re-evaluation on __________ (month/year) due to __________________________________________________ (condition/ disease)
and _______________________________________________________________________________________________ (other factors/comments).”
Turn over to complete reverse side
p.2 MAB102_0318
C. Vision Screening Analysis
Provided said applicant follows the conditions and treatment prescribed on this certificate, in my professional opinion the operator meets the minimum
visual standards required by the Commonwealth of Massachusetts (described below) and therefore is visually qualified to safely operate the following
vehicle(s):
Yes No
................. Ordinary passenger vehicles not being operated to transport passengers for hire, with the following exceptions (if any)
__________________________________________________________________________________________________
I, the undersigned ophthalmologist or optometrist, agree to keep a copy of this Vision Screening Certificate in my office for a 12 month period following
the date of the screening. I hereby certify that the information provided herein is true, accurate, and complete.
Ophthalmologist or Optometrist Name
Massachusetts Registration #
Date of Screening (MM/DD/YYYY)
Office Phone #
Check One
M.D. O.D.
Ophthalmologist or Optometrist Signature: _____________________________________________________ Date: ________________________
NOTE: this certificate will not be accepted by the registry after 12 months from date of Screening.
A photocopy of the certificate will not be accepted. Only a certificate with original writing will be accepted.
To Be Completed by RMV Personnel Only
Reviewed at: _____________________________ Office On: ________________________ By: __________________________________________
Minimum required visual standards:
•
At least 20/40 distant visual acuity (Snellen) in either eye, with or without corrective lenses, AND not less than 120 degrees combined horizontal
peripheral field of vision: Eligible for a license.
•
Between 20/50 - 20/70 distant visual acuity (Snellen) in either eye, with or without corrective lenses, AND not less than 120 degrees combined
horizontal peripheral field of vision: Eligible for a license with a “daylight only” restriction.
•
For bioptic telescopic lens wearers: at least 20/40 distant visual acuity (Snellen) through the telescope, at least 20/100 distant visual acuity (Snellen)
through the carrier lens, at least 20/100 distant visual acuity (Snellen) through the other lens, AND not less than 120 degrees combined horizontal
peripheral field of vision: eligible for a license with a “daylight only” restriction, provided the bioptic telescopic lens meets the criteria described on
t
he front of this document.
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RMV - MAB102 Class D And M Vision Screening Certificate

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Completed 12 May 2020

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