MCSA-5871 Vision Evaluation Report

F orm MCSA-5871 OMB Control Number: 2126-0006

Expiration Date:

U.S. Department of Transportation
Federal Motor Carrier Safety Administration

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 8 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue SE, Washington, D.C. 20590.

VISION EVALUATION REPORT

Name: ______________________________________________________ DOB: ____________________

Driver’s License Number (if applicable): __________________________ State: ____________________

Information for the Individual:

The certified medical examiner must receive this report and begin the physical qualification examination no later than 45 calendar days after an ophthalmologist or optometrist signs this report.

Information for the Ophthalmologist or Optometrist:

This individual is being evaluated as part of the process to determine whether the individual meets the vision standard of the Federal Motor Carrier Safety Administration (FMCSA) to operate a commercial motor vehicle in interstate commerce. This report is required to provide information for an individual who has “monocular vision,” as defined by FMCSA, or did not meet FMCSA’s vision standard at a physical qualification examination. An ophthalmologist or optometrist should complete this report to the best of the ophthalmologist’s or optometrist’s ability based on the evaluation of the individual and knowledge of the individual’s medical history. The determination as to whether the individual meets the vision standard and is physically qualified to drive a commercial motor vehicle will be made by a certified medical examiner on FMCSA’s National Registry of Certified Medical Examiners.

FMCSA defines monocular vision as:

(1) in the better eye, distant visual acuity of at least 20/40 (with or without corrective lenses) and field of vision of at least 70 degrees in the horizontal meridian, and

(2) in the worse eye, either distant visual acuity of less than 20/40 with corrective lenses or field of vision of less than 70 degrees in the horizontal meridian, or both.

For general informational purposes only, to meet FMCSA’s monocular vision standard, an individual must:

(1) have in the better eye distant visual acuity of at least 20/40 (Snellen), with or without corrective lenses, and field of vision of at least 70 degrees in the horizontal meridian;

(2) be able to recognize the colors of traffic signals and devices showing standard red, green, and amber;

(3) have a stable vision deficiency; and

(4) have had sufficient time since the vision deficiency became stable to adapt to and compensate for the change in vision.

Name: ________________________________________________ DOB: _____________________________

PLEASE CHECK / FILL IN REQUESTED INFORMATION (PLEASE PRINT)

1. I am an ophthalmologist  I am an optometrist 

2. Date of vision evaluation: _____________________________ (MM/DD/YYYY)

3. Distant visual acuity (please provide both if applicable):

Uncorrected: right eye: 20/__________ left eye: 20/__________

Corrected: right eye: 20/____________ left eye: 20/__________

Type of correction: glasses  contacts 

4. Field of vision, including central and peripheral fields, utilizing a testing modality that tests to at least 120 degrees in the horizontal. Formal perimetry is required. Attach a copy of the formal perimetry test for each eye and interpret the results in degrees of field of vision.

Right eye: _____________degrees (“normal” or “full” are not acceptable)

Left eye: ______________degrees (“normal” or “full” are not acceptable)

Test used to determine results: __________________________________________________________

5. Is the individual able to recognize the standard red, green, and amber traffic control signal colors?
YES  NO 

6. Date of last comprehensive eye examination: _________________ (MM/DD/YYYY) or unknown 

7. Does the individual have monocular vision as it is defined by FMCSA? YES  NO 

If yes, cause of the monocular vision (describe): ____________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

8. Date the monocular vision began: ____________________(MM/YYYY)

9. Current treatment: ___________________________________________________________ or N/A 

Name: ________________________________________________ DOB: _____________________________

10. Does the individual have any progressive eye condition or disease (e.g., macular edema, cataracts, glaucoma, or retinopathy)? YES  NO 

If yes, provide the condition or disease, date of diagnosis, severity (mild, moderate, or severe), current treatment, and whether the condition is stable. Please enter the information in the table below.

Condition or Disease	Date of Diagnosis	Severity Mild Moderate Severe	Current Treatment	Is Condition Stable? Yes No
a)		  		 
b)		  		 
c)		  		 

11. In your medical opinion, is the individual’s vision deficiency stable? YES  NO 

If yes, date the vision deficiency became stable: ________________(MM/YYYY)

12. In your medical opinion, has sufficient time passed since the vision deficiency became stable to allow the individual to adapt to and compensate for the change in vision and to drive a commercial motor vehicle safely? YES  NO 

13. In your medical opinion, is a vision evaluation required more often than annually? YES  NO 

If yes, how often and why? _____________________________________________________________

Name: ________________________________________________ DOB: _____________________________

14. Additional comments (attach additional pages as needed): ____________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

I attest that I am an ophthalmologist or optometrist and that the information provided is true and correct to the best of my knowledge.

____________________________________________

Date

____________________________________________ _________________________________________________________

Printed Name and Medical Credential Signature

____________________________________________

Professional License Number and State

____________________________________________ _________________________________________________________

Phone Number Email

____________________________________________ _________________________________________________________

Street Address City, State, Zip Code

This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.

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