
VISION SPECIALIST REPORT
Month Day Year
❒ M ❒ F
Name Last First Middle Driver's License Number
Street Address Birth Date Sex
City County ZIP Code Driver Facility Control Number and Date:
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)
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
)
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:
Please check all applicable items:
1. ____ Annual exam
2. ____ Condition stable
3. ____ Condition deteriorating (please explain)
4. ____ Condition warrants monitoring (please explain)
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 _____________________________________
Secretary of State
I. APPLICANT INFORMATION State of Illinois
JESSE WHITE • Secretary of State
DSD X-20.10
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.
VI.
IV. PERIPHERAL SECTION
III. ACUITY SECTION
II. INSTRUCTIONS TO VISION SPECIALIST
V.