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The form explains that a Driver License Examiner may note possible impairment and directs the applicant to a licensed Doctor of Optometry or Doctor of Ophthalmology for assessment. It must be completed and certified by the eye care provider, with the patient signing in the provider’s presence. Sections collect visual acuity, fields of vision, color test results, and doctor certification details, plus the provider’s answers about distant vision, irregularities, and treatment effectiveness.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":20,"@type":76,"position":81},"https://docshare.wps.com/document/exam/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/tennessee-department-of-safety-vision-examination-form/308638/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/tennessee-department-of-safety-vision-examination-form/308638.png","ImageObject",300,407,{"name":92,"@type":93},"Noah","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-05","2026-09-20",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",23,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"Who is required to have the vision examination completed on this form?","Question",{"text":113,"@type":114},"Driver applicants may be asked to visit a licensed eye care professional when the Driver License Examiner screening indicates a possible vision impairment or doubt about safe driving ability.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What does the eye care provider need to do when the examination is finished?",{"text":118,"@type":114},"Complete the form and certification fully, and have the patient sign the form in the provider’s presence. The report is accepted only from a licensed Doctor of Optometry or Doctor of Ophthalmology.",{"name":120,"@type":111,"acceptedAnswer":121},"What information must be recorded on the vision results section?",{"text":122,"@type":114},"The form includes visual acuity for right eye, left eye, both eyes (with present glasses, without glasses, and with best possible correction) and a field of vision entry, plus a color test section.","https://schema.org",{"og:url":83,"og:type":125,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":127,"canonical":83},"index,follow",{"doc_id":129,"site_id":62},308638,1790203026,{"code":4,"msg":5,"data":132},{"doc_id":129,"user_id":133,"nickname":92,"user_avatar":134,"doc_module":4,"category_id":19,"category_name":20,"doc_title":65,"doc_description":67,"doc_content":135,"file_id":136,"file_url":137,"file_type":138,"file_size":139,"view_count":105,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":140,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":141,"faqs":142,"seo_title":143,"seo_description":67,"update_tm":144,"read_time":24,"preview_page_count":4},8796095462418,"https://ap-avatar.wpscdn.com/avatar/80000253c1241d02b47?x-image-process=image/resize,m_fixed,w_180,h_180&k=1778826106357471780","# TENNESSEE DEPARTMENT OF SAFETYAND HOMELAND SECURITYVISION EXAMINATION FORM\n\nImportant information for Driver Applicant  \nThe vision screening by a Driver License Examiner indicates there is a possible vision impairment that wouldaffect your ability to safely operate a motor vehicle.You are being asked to have your vision checked by alicensed eye care Doctor of Optometry or Doctor of Ophthalmology to determine whether your vision can beimproved by eye glasses or eye treatment.  \nIf you have any questions about how wellyou must be able to see to drive on the streets and highways ofTennessee,the Driver's License Examiner will be glad to assist you.  \nDriver License Examiners are prohibited from referring you to or recommending the name of an eye specialist.  \nWhen you return to the Driver Service Center after your eye examination,you must bring this completed formby your eye doctor,along with any new eye glasses or corrective lenses.  \n# FOR DOCTOR OF OPTOMETRY OR OPHTHALMOLOGY ONLY\n\n## Important information for the Eye Care Provider\n\nAllapplicants for a driver license as well s drivers whose record cast doubt on their ability to drive safely,are given vision screenings by the DriverLicense Examiners.When this screening indicates that a vision examination is needed by an eye care professional,the person is asked to visit avision specialist.  \nUpon completion of your eye examination of the driver applicant,please completelyfill out this form and certification.Please have patient sign thisform in your presence.  \nNo recommendations or suggestions are given by the Tennessee Department of Safety and Homeland Security Driver License Examiners as to whicheye specialist to visit.This report can only be accepted from a licensed Doctor of Optometry or Doctor of Ophthalmology.  \nFull Name of Person Examined:                                                   \nFirst  \nLast Name  \nMiddle  \nStreet Address:  \nCity_                    \n                         \n_Zip Code       \nState  \n     \n\n| ACUITY   | RIGHT EYE   | LEFT EYE   | BOTH EYES   | FIELD OF VISON   |\n| --- | --- | --- | --- | --- |\n| WITH PRESENT  \u003Cbr>GLASSES (IF ANY)   | 20/   | 20/   | 20/   | TO RIGHT OF POINT OF  \u003Cbr>FIXATION   |\n| WITHOUT GLASSES   | 20/   | 20/   | 20/   | TO LEFT OF POINT OF FIXATION   |\n| WITH BEST  \u003Cbr>POSSIBLE  \u003Cbr>CORRECTION   | 20/   | 20/   | 20/   | TOTALANGLE   |\n| COLOR TEST   |  |  |  |  |\n\n(OVER)  \nSF-0257(Rev.1/12)  \n# TENNESSEE DEPARTMENT OF SAFETYVISION EXAMINATION FORM\n\n1.Are glasses needed for distant vision?         _Are they being prescribed or fitted?                  \n2.Describe any irregularities such as:Double vision,poor night vision,eye injury,eye disease,poor near vision,etc:  \n3.Will eye glasses improve conditions described in Question 2 above?                                      \n4.Willother treatments improve above-described conditions for the eyes?                  \n5.Is the person named in this report currently undergoing the recommend treatment to improve vision?              \n6.Additional Comments:  \n# CERTIFICATION OF OPHTHAMOLOGIST OR OPTOMETRIST\n\nI,_                                                                \n,being licensed to practice in the  \nspecialty of eye care,in the State of  \n                                ,certify I have personally  \nexamined the eyes of the above named.A true record of this examination appears on this report and he or shesigned below in my presence.  \nSignature of Examining Doctor                                            DATE          Medical License Number                                              STATE                      Office Address                              City_            STATE                ZIP CODE                Office Telephone Number           Signature of Person                                                Receiving Eye Examination","cbCaingBgdsuMgcm","https://ap.wps.com/l/cbCaingBgdsuMgcm","pdf",367026,"English","# Important information for Driver Applicant\n# For Doctor of Optometry or Ophthalmology only\n## Important information for the Eye Care Provider\n# Questions for the Eye Care Provider\n# Certification of Ophthalmologist or Optometrist","[{\"question\":\"Who is required to have the vision examination completed on this form?\",\"answer\":\"Driver applicants may be asked to visit a licensed eye care professional when the Driver License Examiner screening indicates a possible vision impairment or doubt about safe driving ability.\"},{\"question\":\"What does the eye care provider need to do when the examination is finished?\",\"answer\":\"Complete the form and certification fully, and have the patient sign the form in the provider’s presence. The report is accepted only from a licensed Doctor of Optometry or Doctor of Ophthalmology.\"},{\"question\":\"What information must be recorded on the vision results section?\",\"answer\":\"The form includes visual acuity for right eye, left eye, both eyes (with present glasses, without glasses, and with best possible correction) and a field of vision entry, plus a color test section.\"}]","Tennessee Department of Safety Vision Examination Form | PDF",1789870924]