Missouri's Driver License Bureau uses this one-page record when a driver's vision needs an eye examiner's findings during a driver review. The examiner records distance acuity with and without correction and horizontal field width, and a table on the form shows which restriction codes apply at each acuity range.
The driver fills in identification and signs the authorization in the physician's presence; the ophthalmologist or optometrist completes the physician section and signs.
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Vision Examination Record
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The form lists them: corrective lenses (A) for 20/40 or better with correction; a left (Y) or right (T) outside mirror when one eye is 20/100 or worse; daylight only (C) for 20/41 to 20/59; and daylight only with a 45 mph limit (CF) for 20/60 to 20/74.
An ophthalmologist or optometrist completes the physician section, recording distance acuity for each eye and both eyes, horizontal field width and remarks on restrictions, severity or stability. The driver must sign the authorization in the examiner's presence, and the Driver License Bureau makes the final licensing decision.