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Official Illinois Vision Specialist Report Form in PDF

The Illinois Vision Specialist Report form is a crucial document used to assess the vision capabilities of individuals applying for a driver's license in Illinois. When applicants do not meet the state's vision standards during their initial screening, they are referred to a registered vision specialist who completes this report. This form not only records the applicant's visual acuity and peripheral vision but also helps determine whether they can safely operate a motor vehicle, especially when using specialized lenses.

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The Illinois Vision Specialist Report form is a crucial document for individuals seeking to obtain or renew their driver's license in Illinois, especially for those who do not meet standard vision requirements. This form captures essential information about the applicant's vision capabilities, including acuity and peripheral vision, which are vital for safe driving. The report requires detailed personal information, such as the applicant's name, address, and birth date, along with their driver's license number. Vision specialists must conduct a thorough examination and certify the results, indicating whether the applicant meets the minimum visual standards. Specific sections of the form address the use of corrective lenses and provide guidelines for those using prescription telescopic lenses. Additionally, the form mandates that the applicant sign it in the presence of the vision specialist, ensuring the integrity of the information provided. This report remains valid for six months, emphasizing the importance of timely assessments. Understanding the requirements and implications of this form is essential for both applicants and vision specialists alike, as it directly impacts an individual's ability to drive legally and safely in Illinois.

Frequently Asked Questions

What is the Illinois Vision Specialist Report form?

The Illinois Vision Specialist Report form is a document used to assess the visual acuity and peripheral vision of individuals applying for a driver's license in Illinois. If an applicant does not meet the vision standards during a screening, they may be referred to a vision specialist who will complete this form to evaluate their vision capabilities.

Who needs to fill out the Vision Specialist Report?

Vision specialists, who are registered and licensed professionals, are responsible for completing this report. They evaluate applicants who have not passed the initial vision screening required for obtaining a driver's license. The form must be filled out in the presence of the applicant.

How long is the Vision Specialist Report valid?

The report remains valid for six months from the date of the examination. It is essential for applicants to submit the report within this timeframe to ensure their eligibility for a driver's license.

What information is required on the form?

The form requires various details, including the applicant's name, address, date of birth, and driver's license number. Vision specialists must also provide their signature, certificate number, and examination findings, including visual acuity and peripheral vision readings.

What are the minimum visual standards for driving in Illinois?

Applicants must meet specific visual standards to qualify for a driver's license. Without corrective lenses, the minimum acuity must be 20/40. For daylight driving, the acuity can range from 20/41 to 20/70. If an applicant's vision is 20/71 or worse, they do not qualify for a license. Peripheral vision must also meet certain criteria, with a minimum of 70° temporal and 35° nasal vision for monocular applicants.

What if the applicant uses a telescopic lens?

If an applicant requires a prescription-mounted telescopic lens, additional sections of the report must be completed. These sections assess the acuity and peripheral vision while using the telescopic lens. The applicant must also demonstrate specific skills related to using the lens effectively.

Can the report include comments or additional information?

Yes, the vision specialist can include comments in Section V of the form. This section allows for additional observations or recommendations regarding the applicant's vision condition and suitability for driving.

What happens if the vision standards are not met?

If the applicant does not meet the required vision standards, they may be advised to drive only during daylight hours or may not qualify for a driver's license at all. Restrictions may be placed on their driving privileges based on the findings of the vision specialist.

How should the applicant prepare for the examination?

Applicants should ensure they have any necessary corrective lenses with them during the examination. They should also be prepared to follow the vision specialist's instructions closely and be ready to demonstrate their ability to use any prescribed lenses effectively.

Form Specifications

Fact Name	Details
Governing Law	The Illinois Vision Specialist Report is governed by the Illinois Vehicle Code, specifically 625 ILCS 5/6-106.1.
Purpose	This report is required for applicants who do not meet the vision standards necessary for obtaining a driver's license in Illinois.
Validity Period	The report remains valid for six months from the date of the examination.
Vision Standards	Minimum visual acuity standards are set at 20/40 without corrective lenses for unrestricted driving.
Peripheral Vision Requirements	Applicants must have a minimum of 70° temporal and 35° nasal vision for monocular vision to qualify for a driver's license.
Signature Requirement	The applicant must sign the report in the presence of the vision specialist, who also signs and provides their certificate number.
Restrictions for Telescopic Lens	Those using prescription telescopic lenses are limited to driving during daylight hours only.
Additional Documentation	A supplementary sheet can be attached if necessary, provided it is signed and dated.

Common mistakes

Incomplete Personal Information: Failing to fill out all required personal details, such as the applicant's full name, birth date, or address, can lead to processing delays.
Missing Signatures: Not having the applicant sign the report in the presence of the vision specialist can render the form invalid.
Incorrect Acuity Readings: Entering readings that include plus (+) or minus (–) indicators is unacceptable. Only whole numbers should be recorded.
Failure to Complete Sections for Telescopic Lens: If the applicant uses a telescopic lens, all relevant sections must be completed. Omitting these sections can lead to disqualification.
Not Checking Required Items: Forgetting to check applicable items in the comments section can lead to confusion regarding the applicant's driving capabilities.
Ignoring the Stability of Condition: Not indicating whether the applicant's condition is stable or deteriorating can affect the recommendations made for re-examination.
Incorrectly Assessing Peripheral Vision: Miscalculating the temporal and nasal readings can result in an incorrect determination of the applicant's eligibility to drive.

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VISION SPECIALIST REPORT


Name	Last	First	Middle	Driver's License Number

Street Address					Birth Date		Sex
				Month	Day	Year	❒ M	❒ F
							❒ M	❒ F

City		County	ZIP Code	Driver Facility Control Number and Date:

II. INSTRUCTIONS TO VISION SPECIALIST

Applicants applying for an Illinois driver's license may be required to pass a vision screening. If the vision standards are not met, the applicant will be referred to a vision specialist. Driver Services employees do not recommend or suggest which registered vision specialist to contact.

Have the applicant sign and date this report in your presence. Place your signature and certificate number in Section VII. Comments may be entered in Section V. Sections VIII to XI (reverse side) must be completed for an applicant who desires to use a prescription mounted telescopic lens arrange- ment. READINGS WHICH INDICATE A PLUS (+) OR MINUS (–) ARE NOT ACCEPTABLE. (EXAMPLE: 20/40-1 OR 20/100+2)

If needed, a supplementary sheet, which has been signed and dated, may be attached to this report.

I authorize release of the report of this examination to the Secretary of State, Driver Services Department, Springfield, Illinois, for confidential use in my driver's record. This report shall remain valid for six months from the examination date shown below.

____________________________________________		_______________________________________________________
Applicant Signature		Telephone Number (Telescopic Lens Wearer Only)

III. ACUITY SECTION
Minimum Visual Screening Standards—Acuity			(For telescopic lens arrangements complete the report in Section VIII)
				Vision Specialist Examination Certification
Acuity: –	No restrictions = 20/40 (without corrective lenses)			Acuity	Both	Right	Left
–	Daylight driving only = 20/41 to 20/70		With correction		20/	20/	20/
	(with best correction binocular)
–	Failure = 20/71 or less (binocular)		Without correction		20/	20/	20/
–	Left and right outside rearview mirror = to or greater than 20/100 (monocular)

IV. PERIPHERAL SECTION
	Minimum Visual Screening Standards—Peripheral
Peripheral: –	Monocular = 70° temporal and 35° nasal	(For telescopic lens arrangements complete the report in Section VIII)
	(105° total field)	Vision Specialist Examination Certification
–	Binocular = 140° total temporal field	Left Eye		Right Eye		Total Field of
	Temporal Reading			Temporal Reading		Vision*
				+	=
	______________ °			______________ °		______________ °
						(140° or greater – qualification with no
						restrictions. If 139°	or less see below)

*If the total field of vision above equals less than 140° , the applicant may still be able to qualify for a driver's license with restrictions. Screen each eye individually by finding a temporal and a nasal reading. At least one of the eyes must have a minimum temporal reading of 70° and a minimum nasal reading of 35° for a total of 105° in order to qualify with a restriction of both a left and a right outside rearview mirror. If neither eye has at least 70° temporal and 35° nasal, the applicant is not qualified to be licensed to drive in Illinois.

Complete only if received less than 140° total field of vision above:

	Left Eye			Right Eye
Temporal	Nasal	Total	Temporal	Nasal	Total
_________ °	+	=	_________ °	+	=
_________ °	_________ °	_________ °	_________ °	_________ °	_________ °

The specialist will please check all applicable items:

1.	____	Applicant should drive in daylight only.
2.	____	Applicant would not accept correction.
3.	____	Corrective lens(es) were accepted, checked and approved.
		Date: ___________________________

4. ____ Prescription spectacle mounted telescopic lens arrange-

ment. (See reverse.)

Comments:

VI.

Please check all applicable items:

1.	____	Annual exam
2.	____	Condition stable
3.	____	Condition deteriorating (please explain)
4.	____	Condition warrants monitoring (please explain)

5. ____ Other (please explain)

If #3, 4 or 5 is marked, please indicate diagnosis and your recommen- dation for re-examination in ____ 6 months ____ 12 months

____ Other

VII.

I certify that I have personally examined the eyes of the above-named individual and that a true record of my examination appears hereon.

Signature __________________________________________________	Certificate No. ______________________________________
Business Address ___________________________________________	Telephone Number __________________________________
Date of Examination _________________________________________	City/ZIP Code _____________________________________

JESSE WHITE • Secretary of State

DSD X-20.10

This Side of Form to be Completed for Prescription Mounted Telescopic Lens Wearers ONLY

Sections I, II, V, VI, VII and the following sections must be completed for prescription spectacle mounted telescopic lens. Applicants who qualify to drive with the use of a Prescription Telescopic Lens Arrangement shall be restricted to driving during daylight hours only and shall be eligible for a Class "D" driver's license only.

VIII. ACUITY SECTION:
	Minimum Visual Screening Standards—Acuity	Vision Specialist Examination Certification
	Prescription Spectacle Mounted Telescopic Lens(es)
		Acuity	Both	Right	Left
–	Telescopic lens(es) may not exceed 3X wide angle, or 2.2X standard	Through carrier lenses	20/	20/	20/
–	Central acuity through the telescopic lens must be 20/40 or better	Through telescopic lenses	20/	20/	20/
–	Central acuity through the carrier must be 20/100 or better	Without correction	20/	20/	20/

–Left and right outside rearview mirror = to or greater than 20/100 (monocular vision through telescopic lenses)

IX. PERIPHERAL SECTION:

Minimum Visual Screening Standards—Peripheral

Prescription Spectacle Mounted Telescopic Lens(es)

–Peripheral 140° binocular or monocular 70° temporal and 35° nasal with the prescription spectacle mounted telescopic lens(es) in place and without the use of field enhancers

Vision Specialist Examination Certification

Left Eye	Right Eye	Total Field of
Temporal Reading	Temporal Reading	Vision*
	+	=
______________ °	______________ °	______________ °
		(140° or greater – qualification with no restrictions.
		If 139° or less see below)

Complete only if received less than 140° total field of vision above:
	Left Eye					Right Eye
Temporal	Nasal	Total	Temporal			Nasal	Total
_________ °	+	=	_________ °		+	_________ °	=
_________ °	_________ °	_________ °	_________ °			_________ °	_________ °

X.
– Date the applicant received the telescopic lens arrangement				____________________
– Power of the telescopic lens arrangement				____________________
– Is the patient's condition stable?				❒Yes	❒ No
– In your professional opinion, is there any indication that the applicant				❒Yes	❒ No
may not be capable of safely operating a motor vehicle?				❒Yes	❒ No
– Indicate any additional comments or restrictions:

XI.
Has the patient successfully completed all the following requirements:				❒ Yes		❒ No

•The patient has been fitted for a prescription spectacle mounted telescopic lens arrangement and has had this arrangement in his/her possession for at least 60 days prior to the application date.

•The patient has clinically demonstrated the ability to locate stationary objects within the telescopic field by aligning the object directly below the telescopic lens and moving the head down and the eyes up simultaneously.

•The patient has clinically demonstrated the ability to locate a moving object in a large field of vision by anticipating future movement, so that by moving the head and eyes in a coordinated fashion, he/she is able to locate the moving object within the telescopic field.

•The patient has clinically demonstrated the ability to remember what has been observed after a brief exposure, with the duration of the exposure progressively diminished to simulate reduced observation time while driving.

•The patient has experienced levels of illumination which may be encountered during inclement weather or when driving from daylight into areas of shadow or artificial light and the patient has clinically demonstrated the ability to successfully adjust to such changes.

•The patient has experienced walking and riding as a passenger in a motor vehicle so that he/she has practical experience of motion while objects are changing position.

Dos and Don'ts

When filling out the Illinois Vision Specialist Report form, it's important to follow certain guidelines to ensure accuracy and compliance. Here are some key dos and don'ts to keep in mind:

Do have the applicant sign and date the report in your presence.
Do ensure all sections relevant to the applicant's condition are completed, especially if they require a telescopic lens arrangement.
Do provide clear and accurate readings for both acuity and peripheral vision, as these are critical for the applicant's evaluation.
Do attach a supplementary sheet if additional comments or details are necessary.
Don't use readings that indicate a plus (+) or minus (–) as they are not acceptable for this form.
Don't leave any sections blank that are required for the applicant's specific circumstances.
Don't forget to sign and include your certificate number in Section VII to validate the report.

Documents used along the form

The Illinois Vision Specialist Report form is an essential document for applicants seeking a driver's license who do not meet standard vision requirements. Several other forms and documents often accompany this report to ensure comprehensive evaluation and compliance with state regulations. Below are five commonly used documents:

Vision Screening Results Form: This form records the initial vision screening results performed by a certified technician. It provides baseline data on the applicant's visual acuity and peripheral vision before they are referred to a vision specialist.
Medical History Questionnaire: Applicants fill out this form to provide their medical background, including any previous eye conditions or surgeries. This information helps the vision specialist understand the applicant's overall health and any potential factors affecting their vision.
Driver’s License Application: This is the primary form that applicants complete when applying for a driver's license. It includes personal information, residency details, and the applicant's consent for vision testing and reporting.
Prescription Verification Form: If the applicant uses corrective lenses, this form verifies the prescription details from the eye care provider. It ensures that the lenses meet the required standards for safe driving.
Motorcycle Bill of Sale: This document is essential for the transaction between the buyer and seller of a motorcycle, ensuring clarity in the sale terms. For more information, visit allfloridaforms.com/.
Vision Specialist Certification Form: After examination, the vision specialist completes this form to certify the applicant's vision status. It includes the results of the eye exam and any recommendations regarding driving restrictions.

These documents work together to facilitate a thorough assessment of an applicant's vision capabilities, ensuring that only those who meet the necessary standards are granted a driver's license in Illinois. Timely submission and accurate completion of these forms are crucial for a smooth application process.

Misconceptions

Understanding the Illinois Vision Specialist Report form can be challenging. Here are some common misconceptions that people may have:

It is only for people with severe vision problems. Many applicants who may not have severe issues still need to complete this form if they do not meet the standard vision requirements for a driver’s license.
All vision specialists are the same. Not all vision specialists are registered with the state. It is important to choose one who is recognized to ensure the report is valid.
The report is valid indefinitely. The report is only valid for six months from the examination date. After that, a new examination is required.
Applicants can drive immediately after passing the vision test. Even if an applicant passes the vision test, they may still have restrictions on their driving privileges, especially if they require special lenses.
Only one eye needs to meet the vision standards. Both eyes must meet specific criteria for acuity and peripheral vision to qualify for a driver’s license.
Vision correction is optional. If corrective lenses are recommended, the applicant must use them to meet the vision standards.
The form can be completed without the applicant present. The applicant must sign the report in the presence of the vision specialist to ensure authenticity.
Comments from the vision specialist are not important. Comments can provide valuable context about the applicant’s vision condition and any recommendations for driving restrictions.

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