When a Minnesota driver or applicant does not pass the Driver and Vehicle Services vision screening, a licensed vision examiner's report on this form is needed before a license is issued. The examiner records acuity and horizontal fields and recommends restrictions and a reporting interval, and DVS applies Minnesota Rule 7410.2400 to set the final restrictions.
The patient completes and signs Section A in the vision examiner's presence; a licensed vision examiner (optometrist or ophthalmologist) completes and signs Section B on the reverse side.
Download the current version from the source each time; forms change without notice.
Vision Report
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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Section B asks for the date of the last vision exam, which must have been within six months. The examiner then records acuity without lenses, with present lenses and with new lenses, plus horizontal fields in degrees, and recommends restrictions and a reporting interval.
Minnesota Rule 7410.2400, summarized on the form, allows daylight-only, speed, area, road and equipment restrictions. Corrected acuity of 20/50 or less can bring a daylight or speed restriction, and Minnesota statutes may require restrictions other than those the examiner recommends.
The examiner selects how often the patient should submit the form: every 4, 3, 2 or 1 year. The form also asks the examiner to name any impairing condition, describe its effect on seeing while driving and mark it stable or progressive. The current version is PS30338-19, revised October 2026.