[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-310575-105":3,"detail-sidebar-cat-0-en-105":81,"doc-detail-310575-en":131},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","nh-vision-examination-form-eye-examination-part-a","NH Vision Examination Form - Eye Examination - Part A","","NH Department of Safety, Division of Motor Vehicles, provides a vision examination form for applicants seeking a New Hampshire driver license. Part A collects eye examination details and requires completion by a licensed ophthalmologist or optometrist, including the applicant’s visual acuity thresholds (minimum 20/40 with both eyes or 20/30 with one eye). It also specifies valid approval timelines and includes certification checkboxes for capability with no, old, or new corrective lenses.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/nh-vision-examination-form-eye-examination-part-a/310575/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/nh-vision-examination-form-eye-examination-part-a/310575.png","ImageObject",300,407,{"name":42,"@type":43},"Alex Sinclair","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-20",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Who must complete Part A of the NH vision examination form?","Question",{"text":63,"@type":64},"Part A must be completed by a licensed eye doctor, such as an ophthalmologist or optometrist.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What minimum vision acuity is required to obtain an NH driver license?",{"text":68,"@type":64},"The form states minimum requirements of 20/40 with both eyes or 20/30 with one eye.",{"name":70,"@type":61,"acceptedAnswer":71},"What happens if the applicant’s vision is below the minimum level?",{"text":72,"@type":64},"In such cases, certification and recommendation under SAF-C 1004.08 are required, and the Director of Motor Vehicles may issue a license based on the doctor’s unqualified recommendation and related factors.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},310575,1790443952,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,120,123,127],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":116,"doc_module":4,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},9,"Religion & Spirituality",20,"religion-spirituality",{"id":118,"doc_module":4,"doc_module_name":25,"category_name":121,"show_sort_weight":118,"slug":122},"World Cup","world-cup",{"id":124,"doc_module":4,"doc_module_name":25,"category_name":125,"show_sort_weight":124,"slug":126},10,"Lifestyle","lifestyle",{"id":128,"doc_module":4,"doc_module_name":25,"category_name":129,"show_sort_weight":97,"slug":130},19,"General","general",{"code":4,"msg":82,"data":132},{"doc_id":79,"user_id":133,"nickname":42,"user_avatar":134,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":26,"language":140,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":12,"update_tm":144,"read_time":97},1099523882182,"https://ap-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","John J. Barthelmes  \nCommissioner of Safety  \nSTATE OF NEW HAMPSHIRE DEPARTMENT OF SAFETY  \nDivision Of Motor Vehicles  \nStephen E. Merrill Building  \n23 Hazen Drive, Concord, NH 03305 Telephone: 603-227-4050  \nTDD Access: Relay NH 7-1-1  \nElizabeth A. Bielecki  \nDirector of Motor Vehicles  \nPart A  \nEYE EXAMINATION  \nAll applicants for a NH driver license are given simple vision tests by NH-DMV driver licensing personnel. When more accurate measurements are needed or when unusual eye defects seem apparent, the applicant is asked to see an ophthalmologist or optometrist (eye doctor) . A report from an eye doctor is particularly important if the fitness of the driver is ever questioned. Please complete and sign this form and have the person being examined sign the form. Only reports from licensed eye doctors will be acceptable. The eye doctor assumes no responsibility other than that of truthfully representing the facts.  \nForm only valid for 30 days after optometrist/physician signing.  \n(Please print legibly)  \nNAME OF PERSON BEING EXAMINED:   ADDRESS:    \nNAME OF EYE DOCTOR:   ADDRESS:    \nDATE OF EXAMINATION:   PERSON’S DATE OF BIRTH:    \nSTATE ADMINISTRATIVE RULES REQUIRE A MINIMUM OF 20/40 VISION WITH BOTH EYES OR 20/30 VISION WITH ONE EYE.  \nI   , RECOMMEND THAT    \n(Signature of ophthalmologist or optometrist) (Person being examined)  \n􀀀 IS VISUALLY CAPABLE OF OBTAINING A NH DRIVER LICENSE WITHOUT CORRECTIVE LENSES  \n􀀀 IS VISUALLY CAPABLE OF OBTAINING A NH DRIVER LICENSE WITH OLD CORRECTIVE LENSES  \n􀀀 IS VISUALLY CAPABLE OF OBTAINING A NH DRIVER LICENSE WITH NEW CORRECTIVE LENSES  \n􀀀 MAY BE VISUALLY CAPABLE OF OBTAINING A NH DRIVER LICENSE. (Part C must be completed by a medical doctor)  \n􀀀 IS NOT VISUALLY CAPABLE  OF OBTAINING A NH DRIVER LICENSE.  \nPart B  \nNEW CORRECTIVE LENSES  \nNAME OF OPTICIAN:   ADDRESS:    \nI   CERTIFY THAT    \n(Signature of Optician) (Person being examined)  \nHAD NEW CORRECTIVE LENSES FITTED/INSTALLED ON:   PATIENT’S CONSENT: I hereby give my consent that this information be forwarded to the Director of Motor Vehicles.  \n  DATE    \n(Patient’s Signature)  \nDSMV 61 (Rev. 03/16)  \nPart C  \nMedical Condition  \nNOTICE TO THE CERTIFYING MEDICAL DOCTOR  \nThe person requesting your certification of his/her fitness to operate a motor vehicle has been found to possess less than the minimum level of visual acuity usually required for the issuance of a driver license. However, pursuant to SAF-C 1004.08 (reprinted in part below), a person whose visual acuity is determined to be within specific levels may obtain a driver license if the Director of Motor Vehicles determines that he/she is able to safety drive on ALL public highways. Your recommendation and certification of the applicant’s’ ability is one of the criteria which will be considered by the Director in making this determination.  \nIn order for the applicant to be issued a driver license, he/she must receive your UNQUALIFIED certification and recommendation. Accordingly, it is essential that you complete either Section I or Section II of this form . Failure to complete the form in its entirety will result in the rejection of the application.  \nIf you are unable to give an unqualified certification and recommendation in either Section I or Section II, you should not fill out or sign this form.  \nSAF-C 1004.08 Special Visual Acuity Requirements: (a) Notwithstanding any other provision to the contrary, the director shall issue a driver license to an applicant whose visual acuity is between 20/40 and 20/70 . (b) No driver license shall be issued to an applicant whose visual acuity is worse than 20/40 in both eyes, or worse than 20/30 if there is vision in only one eye, unless the following has been completed:  \n( 1) The applicant has submitted form DSMV 61 to the director in accordance with Saf-C 1004.05(b) and (c);  \n(2) The applicant has also submitted form DSMV 61, Part C to the director, which has been completed by an eye doctor; and  \n(3) The eye d","cbCaiffbAjLynXWM","https://ap.wps.com/l/cbCaiffbAjLynXWM","pdf",78849,"English","# Part A\n## Eye Examination Requirements\n## Vision Acuity Standards\n## Certification Options\n# Part C\n## Medical Condition Notice\n## SAF-C 1004.08 Visual Acuity Rules\n## Section I and Section II","[{\"question\":\"Who must complete Part A of the NH vision examination form?\",\"answer\":\"Part A must be completed by a licensed eye doctor, such as an ophthalmologist or optometrist.\"},{\"question\":\"What minimum vision acuity is required to obtain an NH driver license?\",\"answer\":\"The form states minimum requirements of 20/40 with both eyes or 20/30 with one eye.\"},{\"question\":\"What happens if the applicant’s vision is below the minimum level?\",\"answer\":\"In such cases, certification and recommendation under SAF-C 1004.08 are required, and the Director of Motor Vehicles may issue a license based on the doctor’s unqualified recommendation and related factors.\"}]","NH Vision Examination Form - Eye Examination - Part A | PDF",1789884069]