Illinois drivers can bring this report from an eye specialist instead of taking the in-person vision screening at a DMV, and it is the follow-up route after a failed screening. The specialist records acuity and peripheral fields against the Secretary of State's minimum standards, notes restrictions such as daylight-only driving, and completes a separate back page for telescopic (bioptic) lens wearers. The report is valid for six months from the exam date.
The applicant completes Section I and signs the release. A licensed ophthalmologist, optometrist or physician (the form's checkbox reads MD/DO or OD) completes Sections II to V, and Sections VI to IX on the back for telescopic lens wearers only.
The applicant prints their name, address, county, driver's license number, birth date and gender, and signs to release the report to the Secretary of State, Driver Services Department, for confidential use on their driving record. Telescopic lens wearers also give a phone number. The release states the report is valid for six months from the examination date.
Record acuity for both eyes, right and left, with and without correction, without plus or minus notations. The standards printed beside it: 20/40 binocular without corrective lenses means no restrictions, 20/41 to 20/70 with best correction means daylight driving only, 20/71 or less fails, and each eye needs 20/100 or better for outside mirror use. Check daylight driving only, left and right outside rearview mirrors, or applicant would not accept correction where they apply.
Record the left and right temporal readings and the total. A total of 140 degrees or more qualifies with no restrictions. If the total is 139 degrees or less, screen each eye for a temporal and a nasal reading. At least one eye needs 70 degrees temporal and 35 degrees nasal, 105 degrees in all, to qualify with both outside mirrors; if neither eye meets that, the applicant cannot be licensed in Illinois.
Check every item that applies. Item 1, an opinion that the person is or is not visually fit to drive, is required only when the driver is currently canceled because of an earlier vision report. Item 2 confirms corrective lenses were accepted, checked and approved, with the date. Item 3 flags a condition that is deteriorating or warrants monitoring; explain it and choose a re-examination interval of 3, 6 or 12 months or other.
Certify that you examined the applicant's eyes and that the report is a true record. Enter the date of examination, which starts the six-month validity period, sign personally (stamped signatures are not accepted), print your name, and give the phone, business address, professional license number and issuing state, and check MD/DO or OD.
Complete the back only for prescription spectacle-mounted telescopic lens wearers, together with Sections I, IV and V on the front; every reading must be filled in. Record acuity through the carrier lenses (20/100 or better), through the telescopic lenses (20/40 or better) and without correction, for both eyes and each eye, without plus or minus notations. Then record temporal fields and, if under 140 degrees, nasal and temporal readings for each eye.
State whether anything suggests the applicant may not drive safely, confirm the arrangement has been in their possession at least 60 days, give the date received and the power (no more than 3X wide angle or 2.2X standard), and say whether night driving is safe under 92 Ill. Adm. Code 1030.75. Section IX confirms that, after the 60-day period, the patient demonstrated locating stationary and moving objects, short-exposure recall, adjusting to light changes, and experience walking and riding as a passenger.
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Vision Specialist Report
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A licensed optometrist, ophthalmologist or physician, according to the Secretary of State; the form's credential box reads MD/DO or OD. The specialist completes Sections II to V and signs personally, because stamped signatures are not accepted, and adds the professional license number and issuing state. The applicant completes Section I.
Six months from the examination date entered in Section V, as stated in the applicant's release. Telescopic lens wearers must file a new report every year, and the Secretary of State mails a blank report in advance to telescopic lens drivers who have submitted one before.
No. The acuity and telescopic acuity sections both state that readings indicating a plus or minus are not acceptable. Record whole lines, such as 20/40 or 20/100, for right, left and both eyes, with and without correction, so the report is not turned away at the DMV.
Acuity must be 20/40 or better through the telescope and 20/100 or better through the carrier lens, with 140 degrees binocular or 70 temporal and 35 nasal monocular fields. The prescription spectacle-mounted telescope must have been in the driver's possession at least 60 days, and power may not exceed 3X wide angle or 2.2X standard.