DS-6577 Vision Assessment

OMB APPROVAL NO 1405-XXXX
EXPIRATION DATE: XX-XX-20XX
ESTIMATED BURDEN: XX MINUTES

U.S. Department of State

Bureau of Medical Services

DRIVER MEDICAL EVALUATION:
VISION ASSESSMENT FORM
Instructions: This form can be used for individuals who cannot pass the vision acuity or peripheral vision testing (with or without correction), or who
report other vision deficiencies or conditions. This form must be completed by an optometrist or ophthalmologist (or local equivalent).

Section I: Driver Information
Name (Last, First, MI)

Date of Birth (mm-dd-yyyy)

Section II: Vision History
DISTANT VISUAL ACUITY
ACUITY

UNCORRECTED

CORRECTED*

Right Eye

20/

20/

Left Eye

20/

20/

Both Eyes

20/

20/

How was testing performed?

*If corrected, what was the patient wearing during the visual acuity exam?

Contact Lenses

Corrective Lenses

FIELD OF VISION
ACUITY

HORIZONTAL FIELD OF VISION

Right Eye

°

Left Eye

°

How was testing performed?

MONOCULAR VISION
If "Yes", describe treatment, and when it began (mm-dd-yyyy).
Does the individual have
monocular vision with intact
vision in one eye (20/40 with
or without correction)?
Yes

No

PROGRESSIVE EYE DISEASE
Does the individual have a
progressive eye or vision
condition or disease (e.g.,
cataracts, glaucoma,
retinopathy, etc.)?
Yes

Condition

Date of Diagnosis
(mm-dd-yyyy)

Severity

Current Treatment

Stable
Condition?

IF
YES:
Yes

No

No

VISION EXAMS
Do you recommend annual
or more frequent eye
exams?
Yes

Comments

No

RESTRICTIONS
Are there any local
restrictions related to vision
deficiencies and
professional driving?
Yes
DS-6577
03-2024

If "Yes", provide details.

No
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Name of Examinee

DOB

COMMENTS

Section III: Provider/Clinician Recommendation
______________ (initial): I attest that I am an optometrist/ophthalmologist (or equivalent) and have examined and/or
tested the vision of the above listed candidate’s vision.
Based on my assessment above, performed on ________________________ (mm-dd-yyyy):
The individual can safely drive, without restrictions.
The individual can safely drive with the following restrictions/limitations:
The individual should not drive at this time.
Name of Provider/Clinician

Signature of Provider/Clinician

Medical Credential/Specialty
Optometrist
Ophthalmologist
Other:

Clinic Address/Post

Phone Number

Email

*Note: even if the documentation indicates the individual can drive, this document will be reviewed as part of the overall driver medical
evaluation and in accordance with the US Department of State Bureau of Medical Services Driver Medical Evaluation Policy.
Privacy Act Statement
Releases or disclosures of confidential medical information are governed by the Privacy Act of 1974, as amended, 5 U.S.C. § 552a et seq., and the
Rehabilitation Act of 1973, as amended, 29 U.S.C. § 701 et seq.
Paperwork Reduction Act Statement
AUTHORITIES: The information is sought pursuant to 5 CFR 930.108, 339.301 and the Foreign Service Act of 1980, as amended (Title 22 U.S.C. 4084, 3901, and 3984).
PURPOSE: The information requested on this form will be used to determine medical eligibility for issuance of a driver medical certificate.
ROUTINE USES: Unless otherwise protected by law, the information solicited on this form may be made available to appropriate agencies, whether Federal, state, local, or
foreign, for law enforcement and other authorized purposes. The information may also be disclosed pursuant to court order. The information may also be made available to
local Health Units. More information on the Routine Uses for the system can be found in the System of Records Notice State-24, Medical Records
DISCLOSURE: Providing this information is voluntary; however, failure to provide this information may result in denial of a driver medical certification.

The Genetic Information Nondiscrimination Act of 2008 (GINA)
To the individual and/or health care provider completing the medical history review /exam: The Genetic Information Nondiscrimination Act of 2008
(GINA) prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family
member of the individual, except as specifically allowed by this law. To comply with this law, we are asking that you NOT provide any genetic
information when responding to this request for medical information. 'Genetic Information' as defined by GINA, includes an individual's family medical
history, the results of an individual's or family members' genetic tests, the fact that an individual or an individual's family member sought or received
genetic services, and genetic information of a fetus carried by an individual or an individual's family member or an embryo lawfully held by an individual
or family member receiving assistive reproductive services.
DS-6577

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