West Virginia DMV uses this form to get an eye specialist's examination results when a driver's vision needs review. The ophthalmologist or optometrist records uncorrected and best corrected distant acuity, horizontal field in degrees, and any eye disease or injury and how it is compensated, then gives an opinion on safe driving and restrictions. Commercial drivers need an additional section.
The patient completes Part I and must sign it in the vision specialist's presence. A U.S.-licensed ophthalmologist or optometrist completes Part II, Part III for commercial drivers, and the certification.
Download the current version from the source each time; forms change without notice.
Vision Specialist's Exam Results and Certification
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The examination must be performed by a U.S. licensed ophthalmologist or optometrist, who certifies they personally examined the patient's vision and that the patient signed the form in their presence. The patient authorization notes that the specialist assumes no responsibility for licensing by completing the form.
No. The form states it is not to be used for drivers who require bioptic lenses. For other drivers, it records distant vision for each eye and both eyes, uncorrected and best corrected, plus horizontal field of vision in degrees and the specialist's opinion on safe driving.