Get Illinois Vision Specialist Report Form

The Illinois Vision Specialist Report form is a crucial document for individuals applying for a driver's license who may not meet standard vision requirements. This report helps ensure that applicants receive the appropriate evaluation from a certified vision specialist, particularly if their vision screening indicates a need for further assessment. Completing this form accurately is essential for maintaining safety on the roads.

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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, particularly for those who may not meet standard vision requirements. This form is utilized when an applicant fails the initial vision screening and is referred to a registered vision specialist for a more comprehensive examination. It includes essential personal details such as the applicant's name, address, and date of birth, along with specific sections that assess visual acuity and peripheral vision. The report outlines the minimum visual standards necessary for driving, whether with or without corrective lenses, and provides a clear framework for specialists to document their findings. Additionally, there are sections dedicated to the use of prescription telescopic lenses, which require detailed evaluations to ensure the applicant can safely operate a vehicle. The form not only serves as a record of the vision specialist's examination but also authorizes the release of this information to the Secretary of State for confidential use in the applicant's driving record. Understanding the various components of this form is vital for both applicants and vision specialists, as it ensures compliance with state regulations while prioritizing safety on the roads.

Document Breakdown

Fact Name	Fact Description
Purpose of the Form	The Illinois Vision Specialist Report is used to assess the vision of applicants who may not meet the standard vision requirements for a driver's license.
Governing Law	This form is governed by the Illinois Vehicle Code, specifically under the provisions related to driver licensing and vision standards.
Validity Period	The report remains valid for six months from the date of the examination.
Signature Requirement	The applicant must sign the report in the presence of the vision specialist, who also needs to provide their signature and certificate number.
Vision Standards	Minimum visual standards include 20/40 without corrective lenses, and specific requirements for both binocular and monocular vision.
Peripheral Vision Requirements	For monocular vision, at least 70° temporal and 35° nasal are required, totaling 105° to qualify for a driver's license.
Telescopic Lens Use	Applicants using prescription telescopic lenses must meet additional acuity and peripheral vision standards to qualify for a driver's license.
Additional Documentation	If necessary, a supplementary sheet can be attached to the report, provided it is signed and dated.

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Misconceptions

Misconceptions about the Illinois Vision Specialist Report form can lead to confusion for applicants and vision specialists alike. Here are five common misunderstandings:

The form is only for individuals with poor vision. Many believe that the report is only necessary for those who do not meet vision standards. In reality, it can also be required for individuals using corrective lenses or those who have specific vision conditions.
Vision specialists must recommend specific lenses. Some think that vision specialists are required to suggest which lenses to use. However, the form does not mandate that specialists recommend any particular lenses or treatments; their role is to assess vision and report findings.
The report is valid indefinitely. A common belief is that once the report is completed, it remains valid for as long as the individual holds a driver's license. In fact, the report is only valid for six months from the examination date.
Only eye doctors can complete the form. Many assume that only ophthalmologists or optometrists can fill out the report. However, any registered vision specialist can complete the form, as long as they meet the qualifications set by the state.
All applicants must undergo a vision screening. Some people think that every applicant for a driver's license must have a vision screening. This is not true; only those who do not meet the initial vision standards are referred to a vision specialist for further evaluation.

Example - Illinois Vision Specialist Report Form

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 is important to follow specific guidelines to ensure accuracy and compliance. Below is a list of things you should and shouldn't do:

Do have the applicant sign and date the report in your presence.
Do include your signature and certificate number in Section VII.
Do complete Sections VIII to XI if the applicant uses a prescription mounted telescopic lens arrangement.
Do ensure that readings do not indicate a plus (+) or minus (–).
Do attach a supplementary sheet if needed, ensuring it is signed and dated.

Don't leave any required sections incomplete, especially for telescopic lens wearers.
Don't provide recommendations for specific vision specialists; that is not permitted.
Don't accept readings that do not meet the minimum visual screening standards.
Don't forget to check all applicable items in the comments section.
Don't neglect to indicate the stability of the applicant's condition in Section X.

Illinois Vision Specialist Report: Usage Instruction

Filling out the Illinois Vision Specialist Report form is a critical step for applicants who have not met the vision screening standards required for a driver's license. This form must be completed accurately to ensure a smooth process for obtaining a driver's license. Follow the steps below carefully to fill out the form correctly.

Begin by entering the applicant's full name in the designated fields: last name, first name, and middle name.
Input the driver's license number if applicable.
Provide the street address, city, county, and ZIP code of the applicant.
Fill in the birth date using the format Month/Day/Year.
Select the applicant's sex by marking either the box for Male (M) or Female (F).
Complete the Driver Facility Control Number and date if available.
In Section III, record the acuity readings for both eyes, with and without correction, as per the guidelines provided.
For the peripheral section in Section IV, document the temporal and nasal readings for both eyes.
In Section V, check any applicable items regarding the applicant's driving capabilities and corrective lenses.
Section VI requires you to check applicable items regarding the condition of the applicant's vision.
In Section VII, provide your signature and certificate number as the vision specialist, along with your business address and telephone number.
Complete the sections on the reverse side if the applicant is using a prescription mounted telescopic lens arrangement, including acuity and peripheral readings specific to this arrangement.
Ensure all sections are filled out completely and accurately before submitting the form.

After completing the form, it is essential to submit it to the appropriate authorities. This report will remain valid for six months from the examination date. Make sure to keep a copy for your records. If any additional information is required, be prepared to provide it promptly to avoid delays in processing the application.