Michigan's Department of State uses this four-page statement when it needs eye examination findings to decide on licensing or a driver assessment reexamination, and it can also start a tinted-window restriction review. The vision specialist reports acuity for each eye, the horizontal field for both eyes together, ocular diagnoses and recommended restrictions.
The driver completes Sections 1 and 2, including questions on night vision, glare and any bioptic device. An ophthalmologist (MD or DO) or optometrist (OD) completes Sections 3 to 6 and signs the Section 7 certification with their license number.
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Vision Specialist's Statement of Examination
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A vision specialist who is an MD, DO or OD signs Section 7, giving name, address and professional license number. The signature certifies that they reviewed the driver's Sections 1 and 2 and completed Sections 3 through 6. Non-vision conditions go on the separate DA-4P medical statement.
The statement must be based on a vision examination completed within the last six months, and Section 3 asks for the date of that exam. A form missing the horizontal field in degrees is treated as incomplete, which can delay the Department's review.
Yes. To start a review of whether tinted windows are needed for safe driving, the Department accepts either the Vision Statement of Examination or the Medical Statement of Examination. The resulting restriction is a limitation, not a permission: the person may not drive any vehicle without tinted windows.