Nebraska's DMV asks for this two-page eye report when a driver fails the DMV vision screening or is under vision review. The optometrist or ophthalmologist records unaided and best-corrected acuity, telescopic and carrier-lens acuity for bioptic users, Goldmann horizontal fields, diplopia and a retest interval, and the statement is not valid more than 90 days after the exam.
The applicant signs the authorization before the exam; an optometrist or ophthalmologist completes the numbered items and signs, answering items 7 and 8 only for commercial drivers.
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Statement of Vision
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After the applicant is wearing any new lenses needed to reach the best-corrected acuity on page 1; the form says to delay signing until then. The statement is not valid more than 90 days after the examination date, so the exam date must be filled in.
The horizontal field must be measured with a III4e or V4e Goldmann test target or an equivalent, such as the SSA Kinetic V4e isopter test on Humphrey field analyzers. Degrees temporal and nasal are recorded for each eye, and cause and prognosis are needed if the total field is under 140 degrees.
Two items apply only to commercial motor vehicle operators: whether a vision condition that existed before July 30, 1996 has significantly worsened or another condition developed, and whether the driver can recognize standard red, green and amber traffic signal colors.