Manitoba Public Insurance's Driver Fitness unit uses this report when it needs an eye professional's assessment of a driver's vision: for a vision recall, a second opinion, a Medical Review Committee review, a licence class application, a failed vision standard, or a medical or visual suspension. The ophthalmologist or optometrist answers seven questions and, when instructed, plots the visual fields.
An ophthalmologist or optometrist completes questions 1 to 7: visual acuity, horizontal visual fields, colour vision, diagnosis, prognosis and comments. Plotted visual field diagrams are added when the form instructs.
Download the current version from the source each time; forms change without notice.
Report of Visual Examination (Ophthalmologist/Optometrist)
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An ophthalmologist or an optometrist. They answer questions on visual acuity, horizontal visual fields and colour vision, give a diagnosis, prognosis and comments, and plot the visual fields when the form instructs. The completed report goes back to MPI Driver Fitness by the date on the form.
The driver. The form states that the examination is not covered by Manitoba Health, so the individual pays for it. MPI requests the report for vision recalls, second opinions, licence class applications, failed standards, Medical Review Committee reviews and medical or visual suspensions.
No. MPI publishes it as an encrypted PDF without fillable fields, so it is printed and completed by hand. Mail or fax the completed, signed report to MPI Driver Fitness by the date shown on the form.