PennDOT uses this one-page report to judge whether a driver meets Pennsylvania's minimum vision standards, set in 67 Pa. Code § 83.3 for regular drivers and § 71.3(b)(1) for school bus drivers. The examining provider records uncorrected and corrected acuity for each eye and both eyes, the horizontal field of vision and whether lenses are needed, then returns it to the Bureau of Driver Licensing.
An optometrist, ophthalmologist, physician assistant, certified registered nurse practitioner or licensed physician with equipment to properly evaluate vision completes everything after the patient information and signs. The patient information block identifies the driver and asks whether they are a CDL driver.
Check whether the patient is a CDL driver. Enter the driver's license number, last name with any suffix, first name, height in feet and inches, sex, eye color, date of birth, telephone number and email address if applicable. Give the actual street address with city, state and zip code; a P.O. box may be added but cannot be the only address.
Record visual acuity as 20/ values for the right eye (R), left eye (L) and both eyes (B), in two sets: uncorrected and corrected. Fill both when the patient wears lenses. These are the measurements PennDOT checks against the minimum vision standards in 67 Pa. Code § 83.3, the regulation its Medical Reporting Forms page cites for this form.
Answer Yes or No: (1) do you consider this person visually capable to drive; (2) is the combined field of vision at least 120 degrees in the horizontal meridian, excepting normal blind spots; (3) must the individual wear corrective lenses; (4) is correction obtained through telescopic lenses, which requires form DL-102BD; and (5) does the condition warrant monitoring by the Department, and if so, how often.
For S endorsement holders, answer Yes or No: at least 20/40 in the better eye and 20/50 in the poorer eye, without lenses or corrected; binocular acuity of at least 20/40; a combined horizontal field of at least 160 degrees excepting normal blind spots; ability to identify standard red, green or amber traffic signal colors; and whether the individual must wear corrective lenses.
Indicate whether the patient has had an annual dilated eye exam and give its date. Then mark the result: no diabetic retinopathy detected; background retinopathy detected that only requires monitoring with no treatment indicated; or retinopathy requiring further testing or treatment detected.
Print or type your name, specialty, license number, street address, city, state, zip code, telephone and fax numbers. Sign and date the statement that the facts are true and correct to the best of your knowledge, information and belief, made subject to 18 Pa. C.S. § 4904 on unsworn falsification to authorities.
Download the current version from the source each time; forms change without notice.
Report of Eye Examination
A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.
Sources for this guide
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The form is to be completed by an optometrist, ophthalmologist, physician assistant, certified registered nurse practitioner, or licensed physician with equipment to properly evaluate vision. The provider prints their name, specialty, license number and contact details in the Health Care Provider's Information block and signs a statement made subject to the penalties for unsworn falsification to authorities.
The school bus (S endorsement) block asks whether the driver has at least 20/40 in the better eye and 20/50 in the poorer eye, with or without correction, binocular acuity of at least 20/40, a combined horizontal field of at least 160 degrees, and the ability to identify red, green and amber traffic signal colors. It also asks about lenses and an annual dilated eye exam.
Yes. PennDOT's Medical Reporting Forms page offers the DL-102 as a PDF and as an online version that is completed and signed electronically through DocuSign. The paper form can also be returned to the Bureau of Driver Licensing by mail, fax or email using the details printed at the top of the form.
Answer Yes to item 4 in the regular driver block, which asks whether correction is obtained through telescopic lenses, and complete form DL-102BD as the item instructs. The other regular driver questions, including visual capability, the 120-degree field and lens use, are still answered on the DL-102 itself.