Utah's Driver License Division relies on this one-page report from a vision health care professional to judge whether a driver's eyesight meets its standards. The examiner records acuity with and without correction, whether each eye meets the 120-degree field standard and, if not, whether fields reach 90 or 60 degrees. The examiner then recommends a review time frame, restrictions and any driver testing.
The driver fills in the identity block and signs; a vision health care professional completes everything below it, including required items such as exam date, printed name, signature and degree.
Download the current version from the source each time; forms change without notice.
Certificate of Visual Examination
If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.
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.
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The form asks whether the field is 120 degrees, 60 degrees to both the right and left of fixation, for each eye and both eyes. If it is less, the examiner answers whether it reaches at least 90 degrees, 45 to each side, and if not, at least 60 degrees, 30 to each side.
A vision health care professional. The examiner gives the exam date, printed name, signature and degree, state license number, form signed date and office address, and the starred items are required for the submission to be accepted.
DLD will not accept a submission older than 6 months or one missing required medical information. Forms sent through the Medical Portal may be added the same day, while email and fax take 2 to 3 business days after receipt.