DLAB-2

License No.

STATE OF WEST VIRGINIA

Date

DEPARTMENT OF TRANSPORTATION

DIVISION OF MOTOR VEHICLES

Applicant’s full name:

Street Address

City

State

Date of Birth

REPORT ON VISUAL EXAMINATION

Distant

Vision Only

Right

Eye

Left

Eye

Both
Eyes

EVIDENCE OF SUPPRESSION

TEST USED

Without

Glasses

20/

COORDINATION

@ 20 ft. EXO

ESO

RT. H.

LF. H.

@ 20 ft. EXO

ESO

RT. H.

LF. H.

With

Present

Glasses

20/

FUSION-DISTANCE

EXCELLENT

GOOD

POOR

NONE

TEST USED

With New

Prescription

20/

FUSION-NEAR

EXCELLENT

GOOD

POOR

NONE

TEST USED

If Possible Measure Above @ 20 Ft.

If Not, Please State Dist. Used.

DEPTH PERCEPTION

EXCELLENT

GOOD

POOR

NONE

TEST USED

Fields – Horizontal Perception

Rt.° Lt. ° Total°

COLOR VISION

NORMAL

DEFICIENT

FAIL

TEST USED

To Examining Doctor:

Kindly complete this form. Please leave blank any spaces for test on which you have made no examination. If the case is peculiar, any additional comments on a separate sheet would be appreciated

IMPORTANT: For proper identification, will you please have the person whom you have examined sign the report in your presence.

Sign here:

Are corrective lenses needed for distant vision?

For near vision?

Is there any double vision?

If so, is it corrected with glasses or other treatment?

Any evidence of eye disease or injury?

If so, describe:

Can this be corrected or compensated for?

Any visual difficulty in seeing in dim light or at night?

In your opinion, does this person have sufficient vision to operate a motor vehicle safely?

If yes, should

there be any restrictions imposed?

If so, what restrictions?

Comments:

CERTIFICATON OF VISION SPECIALIST

, being licensed to practice in West Virginia, certify that I have

personally examined the vision of the above named, that a true record of this examination appears on this report and that he or she

signed this form in my presence.

Signature of examining doctor:

Business address:

Date: