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In Tennessee, ensuring the safety of drivers and all road users is paramount, which is why the Department of Safety and Homeland Security has mandated a comprehensive vision examination as part of its driver's license application process. Through the screening conducted by Driver License Examiners, individuals who exhibit potential vision impairments are identified and required to undergo a further eye examination by a licensed eye care professional—either a Doctor of Optometry or Doctor of Ophthalmology. This additional scrutiny helps to ascertain whether vision difficulties can be mitigated through corrective measures like eyeglasses or medical treatment. The examination form serves as a critical document that captures essential information: the applicant's personal details, the eye professional's assessment of the applicant's vision acuity and field of vision, the necessity for glasses, any observed irregularities, and potential treatments to improve vision conditions. Importantly, this process underscores a clear separation of roles, prohibiting Driver License Examiners from recommending specific eye specialists, thereby ensuring impartiality. Applicants are then required to return to the Driver Service Center with the completed form and, if necessary, new corrective lenses, to proceed with their application—a step that underscores the commitment of the Tennessee Department of Safety and Homeland Security to road safety and driver responsibility.

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TENNESSEE DEPARTMENT OF SAFETY

AND HOMELAND SECURITY

VISION EXAMINATION FORM

Important information for Driver Applicant

The vision screening by a Driver License Examiner indicates there is a possible vision impairment that 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.

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.

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.

FOR DOCTOR OF OPTOMETRY OR OPHTHALMOLOGY ONLY

Important information for the Eye Care Provider

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.

Upon completion of your eye examination of the driver applicant, please completely fill out this form and certification. Please have patient sign this form in your presence.

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. This report can only be accepted from a licensed Doctor of Optometry or Doctor of Ophthalmology.

Full Name of Person Examined: _________________________________________________________________________________________

FirstMiddleLast Name

Street Address: __________________________________________________________ City ______________________________________________ State ___________ Zip Code ___________

ACUITY

RIGHT EYE

LEFT EYE

BOTH EYES

FIELD OF VISON

 

 

 

 

 

 

 

 

 

 

WITH PRESENT

 

 

 

TO RIGHT OF POINT OF

20/

20/

20/

FIXATION

GLASSES (IF ANY)

 

 

 

 

 

 

 

 

 

 

20/

20/

20/

TO LEFT OF POINT OF FIXATION

WITHOUT GLASSES

 

 

 

 

 

 

WITH BEST

 

 

 

TOTAL ANGLE

POSSIBLE

20/

20/

20/

 

CORRECTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

COLOR TEST

 

 

 

 

 

 

 

 

 

SF-0257 (Rev. 1/12)

(OVER)

- 1 -

RDA 1348

TENNESSEE DEPARTMENT OF SAFETY

VISION EXAMINATION FORM

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 above?_______________________________________

4.Will other treatments improve above-described conditions for the eyes? ____________________________________

__________________________________________________________________________________________________

5.Is the person named in this report currently undergoing the recommend treatment to improve vision? ______________

6.Additional Comments:

__________________________________________________________________________________________________

CERTIFICATION OF OPHTHAMOLOGIST OR OPTOMETRIST

I, _____________________________________________________________, being licensed to practice in the

specialty of eye care, in the State of ___________________________________, certify I have personally

examined the eyes of the above named. A true record of this examination appears on this report and he or she signed below in my presence.

Signature of Examining Doctor ______________________________________ DATE _________________

Medical License Number ________________________________________ STATE _________________

Office Address ________________________________________________City _________________________

STATE _____________ ZIP CODE _____________Office Telephone Number ________________________

Signature of Person ____________________________________________ DATE _____________________

Receiving Eye Examination

SF-0257 (Rev. 1/12)

- 2 -

RDA 1348

Document Data

Fact Name Description
Purpose of the Form This form is used to document the vision examination required for driver license applicants in Tennessee who have been identified by a Driver License Examiner as possibly having a vision impairment that could affect their ability to drive safely.
Required by Whom The examination must be conducted by a licensed Doctor of Optometry or Doctor of Ophthalmology.
Submission Requirement Upon completion of the eye examination, the applicant must return to the Driver Service Center with this completed form signed by the examining eye care provider, alongside any new eyeglasses or corrective lenses if prescribed.
Prohibition for Driver License Examiners Driver License Examiners are prohibited from referring or recommending specific eye specialists to applicants.
Governing Law This form is regulated by the Tennessee Department of Safety and Homeland Security, adhering to state law requirements for driver's license eligibility concerning vision standards.

Detailed Guide for Using Tennessee Drivers License

Once a Driver License Examiner determines a potential vision impairment that might impact your ability to safely operate a motor vehicle, the next step involves undergoing a professional eye examination. The examination must be conducted by a licensed Doctor of Optometry or Doctor of Ophthalmology. This is to ascertain whether corrective measures, such as glasses or other treatments, are necessary. Upon completion, the examined individual is required to bring the completed form, provided by the eye care professional, back to the Driver Service Center, along with any corrective eyewear prescribed. Here is how to complete the form:

  1. Enter the full name of the person examined, including first, middle, and last names, in the designated space.
  2. Provide the street address, city, state, and zip code of the person examined.
  3. Under "ACUITY," fill in the visual acuity for the right eye, left eye, and both eyes:
    • Record the results with present glasses if any.
    • Record the results without glasses.
    • Record the results with the best correction possible.
  4. For the "FIELD OF VISON" section, input the total angle possible to the right and left of the point of fixation with and without glasses or best correction.
  5. Answer whether glasses are needed for distant vision and if they are being prescribed or fitted.
  6. Describe any irregularities such as double vision, poor night vision, eye injury, eye disease, poor near vision, etc., in the provided space.
  7. Indicate if eye glasses will improve the conditions described above.
  8. Specify if other treatments will improve the conditions described for the eyes.
  9. Confirm if the person named in the report is currently undergoing the recommended treatment to improve vision.
  10. Any additional comments regarding the individual's vision or examination can be added in the "Additional Comments" section.
  11. The certifying Ophthalmologist or Optometrist must fill in their name, certify that they have examined the eyes of the named individual, and provide a true record of the examination in the certification section. They must include their signature, date, medical license number, state, office address, city, state, zip code, and office telephone number.
  12. The person receiving the eye examination must sign and date the form in the designated area at the bottom of the form.

Important Questions on This Form

What is the Tennessee Vision Examination Form?

The Tennessee Vision Examination Form is a document issued by the Tennessee Department of Safety and Homeland Security. This form is used to verify that an individual has the necessary visual acuity and field of vision to safely operate a motor vehicle. It must be completed by a licensed Doctor of Optometry or Doctor of Ophthalmology after performing an eye examination on the driver applicant. The form includes areas to report visual acuity, field of vision, and any need for corrective lenses or other treatments.

Why might someone need to have their vision examined and fill out this form?

Individuals might need to undergo a vision examination and fill out the Tennessee Vision Examination Form for several reasons. Most commonly, this is required if a Driver License Examiner suspects a vision impairment based on a preliminary vision screening. This form is also needed for driver license applicants and for drivers whose records suggest a potential inability to drive safely due to visual limitations.

Who is authorized to complete the Vision Examination Form?

Only licensed Doctors of Optometry or Doctors of Ophthalmology are authorized to conduct the eye examination and complete the Vision Examination Form. The form must be fully filled out by the eye care provider, certifying the visual acuity and field of vision of the person examined.

What information is required on the Vision Examination Form?

The form requires several pieces of information, including:

  • The full name and address of the person examined.
  • Visual acuity for the right eye, left eye, and both eyes, with and without corrective lenses if applicable.
  • The total angle of the field of vision.
  • Whether glasses or other treatments are needed, including if they are being prescribed or fitted.
  • Any irregularities such as double vision, poor night vision, eye injury, eye disease, or poor near vision.
  • The signature of the examining doctor, their medical license number, office address, and telephone number.
  • The signature of the person receiving the eye examination.

Are Driver License Examiners allowed to recommend an eye specialist?

No, Driver License Examiners are strictly prohibited from referring or recommending any specific eye specialists to individuals. It is the responsibility of the person in need of the examination to select and visit an eye care professional of their choice.

What happens after the eye examination is completed?

After the eye examination is completed and the Vision Examination Form is filled out, the individual must return to the Driver Service Center. They must bring the completed form along with any new eye glasses or corrective lenses prescribed by the eye care provider. This will be reviewed by the Department of Safety and Homeland Security to determine the individual’s eligibility for obtaining or retaining a driver's license.

Is there a specific time frame within which the Vision Examination Form should be submitted after the examination?

While the Tennessee Department of Safety and Homeland Security does not specify a strict time frame for submitting the Vision Examination Form after an eye examination, it is advisable to do so as soon as possible. Delaying the submission can delay the process of obtaining or renewing a driver's license. Individuals are encouraged to consult with their local Driver Service Center for more detailed information regarding submission deadlines and requirements.

Common mistakes

Filling out the Tennessee Driver's License form, particularly the Vision Examination Form, is a straightforward process, but mistakes can happen. These errors can delay the application process, sometimes requiring a redo of the form or additional documentation. Here are six common mistakes people make when filling out this form:

  1. Not verifying the eye care professional’s credentials. It's crucial that the examination be completed by a licensed Doctor of Optometry or Doctor of Ophthalmology, as specified. An oversight in confirming the practitioner's qualifications can lead to the rejection of the form.
  2. Incomplete information. Skipping fields or partially completing sections, especially in areas detailing the full name, address, and eye condition specifics, is a frequent error. Each portion of the form provides critical information for assessing the applicant's vision and eligibility, meaning all fields should be meticulously completed.
  3. Misinterpretation of vision acuity and field of vision sections. These areas require precise entries to reflect the applicant's vision capabilities accurately, both with and without glasses. Misunderstanding how to report these values could inaccurately represent one’s vision, affecting the outcome.
  4. Overlooking the signature requirement. Both the applicant and the examining eye care provider must sign the form. It’s a common mistake for one party to forget to sign, which invalidates the application until correctly completed.
  5. Failure to describe vision irregularities fully. Vagueness or omission in detailing vision irregularities such as double vision, poor night vision, or eye disease can hinder the assessment process. Accurate descriptions provide a better understanding of the applicant's health and needs.
  6. Not including new prescriptions. If glasses or corrective lenses are prescribed or changed following the examination, failing to note this on the form or bring the new glasses or lenses to the Driver Service Center may cause unnecessary delays or additional visits.

Avoiding these mistakes can streamline the process of applying for a driver's license in Tennessee. It’s all about attention to detail. Ensure that the form is filled out accurately and completely, confirm the eye care professional’s qualifications, and double-check everything before submission. By doing so, applicants can help ensure a smoother path to obtaining or renewing their driver's license.

Documents used along the form

When applying for or renewing a Tennessee Driver's License, several other forms and documents might be required or prove helpful during the process. These documents ensure that all prerequisites are met, and provide a smooth interaction with the Department of Safety and Homeland Security. Let's take a look at some commonly used forms and documents that accompany the Tennessee Driver's License application.

  • Proof of Identification and Legal Presence - A document that verifies the applicant's identity and legal status in the United States, such as a birth certificate or passport.
  • Proof of Tennessee Residency - Documents showing the applicant's address in Tennessee, like a utility bill or lease agreement, which verify residency in the state.
  • Proof of Social Security Number - A document like a social security card or W-2 form that verifies the applicant's social security number.
  • Application for Tennessee Driver License - The main application form where the applicant provides personal information, driving history, and other relevant details.
  • Real ID Documentation - If applying for a Real ID-compliant license, additional documents, such as proof of identity, proof of legal presence, and two proofs of Tennessee residency, are required.
  • Proof of Name Change (if applicable) - Documents like a marriage certificate or court order for individuals who have changed their name and need to reflect this change on their driver license.
  • Road Skills Test Appointment Confirmation - A confirmation slip indicating the scheduled date and time for the applicant’s road test, if applicable.
  • Tennessee Intermediate Driver License Form (for teens) - Teens applying for their intermediate license must fill out this form, which also requires a parent or guardian’s signature.
  • Certificate of 50 Hours Behind the Wheel Driving Experience - A form that certifies a teen driver has completed the required hours of supervised driving practice. This is necessary for intermediate license applicants.
  • Medical Evaluation Form - Required for applicants with certain medical conditions that might affect their ability to drive safely. This form must be completed by a certified medical professional.

These documents play vital roles in verifying the eligibility and identity of the applicant, ensuring that all drivers on Tennessee roads have met the necessary requirements for safe driving. Should an applicant have questions about these forms, the staff at the Driver Service Center are always ready to provide assistance, keeping the roads safe for everyone.

Similar forms

The Passport Application Form, similar to the Tennessee Drivers License form, requires personal information and certification by an authority—in the passport's case, a government official. Both forms include sections for full names, addresses, and official use only, with strict guidelines for completion. They are integral in verifying the identity of the applicant and ensuring all necessary qualifications are met for the issuance of the document.

The Medical Examination Report Form for Commercial Driver License (CDL) closely resembles the vision examination portion of the Tennessee Drivers License form. Both necessitate a health professional's assessment and signature to confirm the applicant meets specific health criteria. These forms are crucial in determining the ability of individuals to safely operate a vehicle, with a focus on public safety and the well-being of the driver.

The Voter Registration Form shares similarities with the Driver License form in collecting personal information necessary for eligibility determination. Both documents serve as gateways to exercising legal rights and privileges, be it voting or driving. They ensure individuals meet the set requirements, like residency and identity verification, fostering civic participation and legal compliance.

The Social Security Card Application Form, like the Drivers License form, is used to establish identity and eligibility. Both require personal details and are foundational documents that support an individual's legal and official activities in the United States. They are key to accessing various services, benefits, and responsibilities under federal and state laws.

The Employment Eligibility Verification Form (I-9) parallels the identity and eligibility verification aspects of the Tennessee Drivers License form. Employers use the I-9 to verify the legal status and eligibility to work of their employees, much like how the Drivers License form is used to verify a person's eligibility to drive. Both involve legal attestations and the necessity for accurate, truthful information.

The Gun Permit Application, while distinct in purpose, has similar requirements for personal information, background checks, and third-party verification as the Tennessee Drivers License form. Both involve an assessment of eligibility and responsibility, aiming to ensure the individual’s ability to safely and legally operate or possess potentially dangerous assets. Their processes include reviews by authorities to prevent misuse and enhance public safety.

The Marriage License Application also shares commonalities with the Tennessee Drivers License form. Both involve state-issued documents requiring personal details and legal attestations to grant a specific license or permit. These forms play a pivotal role in legalizing personal statuses and activities, requiring official submissions and sometimes third-party certifications.

Lastly, the Application for Enrollment in Public School resembles the structure of providing personal information, guardians' details, and adherence to specific eligibility criteria—similarly seen in the Drivers License form. Both are essential for accessing certain rights and privileges, in this case, education versus driving. They ensure readiness and qualification for the activities or benefits sought, aligned with legal and safety standards.

Dos and Don'ts

When filling out the Tennessee Drivers License vision examination form, there are important dos and don'ts to keep in mind to ensure the process goes smoothly and effectively. Here's a guide to help applicants navigate this process correctly:

Do:

  • Ensure accuracy: Verify all personal information for correctness before submission, including full name, address, and date of the eye examination.
  • Review the form: Before visiting your eye care provider, go through the form to understand the type of information required.
  • Bring necessary eyewear: If you use glasses or corrective lenses, bring them to your eye examination as well as when you return to the Driver Service Center.
  • Follow up: If your eye care provider prescribes new glasses or treatment, take the recommended steps and obtain the necessary eyewear before your license is issued or renewed.
  • Keep copies: Make a copy of the completed form for your records before handing it to the Driver Service Center.

Don't:

  • Omit information: Do not leave any section of the form blank. If a question does not apply, write "N/A" to indicate this.
  • Delay submission: Avoid postponing the eye examination or the submission of the form. Timeliness is key to ensure your driving privileges are not affected.
  • Alter the form: Do not make unauthorized changes or alterations to the form after your eye care provider has completed and signed it.
  • Forget the signature: Ensure both you and your eye care provider sign the form where required. Unsigned forms will not be processed.
  • Ignore eye care provider advice: If additional eye care or a follow-up visit is recommended, do not ignore this advice. Your ability to safely operate a vehicle may depend on it.

Misconceptions

When dealing with the Tennessee Drivers License vision examination form, there are several misconceptions that can arise due to misunderstanding the requirements and procedures detailed within the document. It's important to address these misconceptions to ensure clarity and streamline the process for applicants.

  • Misconception 1: You can choose any professional for your eye examination. It's crucial to understand that the form can only be completed by a licensed Doctor of Optometry or Doctor of Ophthalmology. This specification is designed to ensure that only qualified eye care professionals, who meet state requirements, conduct the vision examination necessary for driving.
  • Misconception 2: Driver License Examiners can recommend eye specialists. The Department explicitly prohibits Driver License Examiners from referring or recommending specific eye specialists. This policy is in place to prevent any bias or unfair advantage, ensuring all applicants have the freedom to choose their own licensed eye care provider without influence from the examining officers.
  • Misconception 3: Prescription glasses or treatments are not needed if you pass the vision screening. Even if you pass the initial vision screening conducted by the Driver License Examiner, glasses or other treatments may still be recommended or prescribed by your eye doctor to address conditions that might not have impacted your ability to pass the screening but could affect your long-term visual health or safety on the road.
  • Miscontribution 4: The vision examination form is complex and difficult to complete. While the form requires detailed information, it's designed to be straightforward for eye care professionals to fill out following a comprehensive eye exam. The sections requiring input from the doctor are clearly marked and focus on essential information regarding vision acuity, field of vision, and any corrective measures needed.
  • Misconception 5: The form is the final step in the vision testing process for obtaining a driver's license. Submitting the completed vision examination form is a crucial step in determining your eligibility for a driver's license, but it’s not the final step. Depending on the results, additional documentation or follow-up exams may be required. Moreover, applicants must meet other criteria and complete further tests, such as the road skills test, to obtain their license.

Understanding these misconceptions can help applicants navigate the process more effectively, ensuring all requirements are met for the safety of the driver and the public. It is advisable for individuals to carefully review the vision examination form and consult with qualified eye care professionals to address any vision impairments or questions.

Key takeaways

Filling out the Tennessee Driver's License Vision Examination Form is an important step for individuals who have been identified as having a possible vision impairment that could impact their ability to safely operate a motor vehicle. Here are some key takeaways regarding the process:

  • Individuals are required to undergo a vision screening by a Driver License Examiner as part of the driver's license application or renewal process. This is to determine if there's a potential vision impairment.
  • If the screening indicates a vision examination by a professional is needed, applicants must visit a licensed eye care Doctor of Optometry or Doctor of Ophthalmology for further evaluation.
  • The eye care provider must fill out the vision examination form completely after evaluating the applicant's vision. This includes assessments of acuity, field of vision, and any need for corrective lenses.
  • Applicants must return to the Driver Service Center with the completed vision examination form, alongside any new eyeglasses or corrective lenses prescribed by the eye doctor, to proceed with their driver's license application or renewal.
  • Driver License Examiners are not allowed to recommend specific eye specialists, ensuring the process remains unbiased and the applicant can choose an eye care provider based on their own preference.
  • The vision examination form includes sections for the eye care provider to report on the necessity of glasses for distant vision, describe any vision irregularities, and recommend any treatments or corrective measures that can improve the applicant’s vision condition.

This detailed form serves as a crucial tool in ensuring that all drivers on Tennessee roads have the vision capability required for safe driving, safeguarding both the individual driver and the wider community.

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