Form MCSA 5871 MCSA 5871 Vision Evaluation Report

OMB No.: 2126-0006
Expiration Date:

Form MCSA-5871
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, DC 20590.

VISION EVALUATION REPORT
Name:

DOB:

Driver’s License Number:

State:

Information for the Individual:
The medical examiner must receive this report and begin the physical qualification examination not more 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 medical examiner on FMCSA’s National
Registry of Certified Medical Examiners.

DRAFT

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 pass since the vision deficiency became stable to adapt to and compensate for the change
in vision.

1
**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.**
Rev 1/18/22

OMB No.: 2126-0006
Expiration Date:

Form MCSA-5871
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Name:

DOB:

PLEASE CHECK/FILL IN REQUESTED INFORMATION (PLEASE PRINT):
1. I am:

an ophthalmologist

an optometrist

2. Date of vision evaluation (MM/DD/YYYY):
3. Distant visual acuity (select N/A if there is no vision in an eye):
Uncorrected: Right eye: 20/
or N/A
Left eye: 20/
Corrected:
Right eye: 20/
or N/A
Left eye: 20/
Glasses
Contacts
Type of correction:

or N/A
or N/A

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)
ATTACH FILE
Test used to determine results:
5. Is the individual able to recognize the standard red, green, and amber traffic control signal colors?

DRAFT

6. Date of last comprehensive eye examination (MM/DD/YYYY):

7. Does the individual have monocular vision as it is defined by FMCSA?

Yes

Yes

No

or

Date unknown

or

N/A

No

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

8. Date the monocular vision began (MM/DD/YYYY):
9. Current treatment:

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:
a. Condition or disease:
Date of diagnosis:

Severity:

Mild

Moderate

Severe

Current treatment:
Is condition stable?

Yes

No If no, why:

2
**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.**

OMB No.: 2126-0006
Expiration Date:

Form MCSA-5871
U.S. Department of Transportation
Federal Motor Carrier Safety Administration
Name:

DOB:

b. Condition or disease:
Severity:

Date of diagnosis:

Mild

Moderate

Severe

Mild

Moderate

Severe

Current treatment:
Is condition stable?

Yes

No If no, why:

c. Condition or disease:
Severity:

Date of diagnosis:
Current treatment:
Is condition stable?

Yes

No If no, why:

11. In your medical opinion, is the individual’s vision deficiency stable?

Yes

No

If yes, provide the date the vision deficiency became stable (MM/DD/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

DRAFT

13. In your medical opinion, is a vision evaluation required more often than annually?

Yes

No

If yes, how often and why?

14. Additional comments (attach additional pages as needed)

ATTACH FILE

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

Professional License Number and State

Signature

Phone Number

Email

Street Address

City, State, Zip Code
3

**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.**