VISION REPORT - Section A/B (Reverse Side) - Data Privacy & Restriction Information - Minnesota

Oct 13, 2026

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Minnesota Department of Public Safety Driver and Vehicle Services vision report form for assessing whether an applicant’s eyesight is sufficient for safe operation of motor vehicles. Sections A and B require completion and signatures by the patient and a licensed vision examiner, respectively. The document explains data privacy use and legal requirements, outlines possible driving restrictions (daylight, speed, area, road, and equipment/field-of-vision), and collects detailed vision acuity, peripheral vision, safety-driving feedback, and vision-problem status.

LanguageEnglish

CategoryLetters

FormatPDF

Pages2

Reading Time1 min

AccessFree to download

VISION REPORT

Section A (Reverse Side)

Section B (Reverse Side)

Data Privacy

Restriction Information

Vision Problems

Vision Acuity & Peripheral Vision

Examiner Certification

MINNESOTA DEPARTMENT OF PUBLIC SAFETY Driver and Vehicle Services445 Minnesota Street,Suite 180St.Paul,MN 55101-5180 Phone:651-296-6911 FAX:651-282-2463 TTY:651-282-6555 Internet:www.mndriveinfo.org # VISION REPORT ■Section A-(Reverse Side)Must be completed and signed by patient in the presence of the vision examiner ■ Section B-(Reverse Side)Must be completed and signed by a licensed vision examiner ■Minnesota statutes may require driving restrictions other than those recommended by the icensed vision examiner ■ Submit the form: by mail -send to the address listed above by FAX-651-282-2463 in person -bring to any Driver's License Exam Station ## DATA PRIVACY A the information collected on this form is required by law.This data is used by authorized Driver and Vehicle Services divisionpersonnel to ensure that those with insufficient vision take the steps required to achieve the best vision possible and to denydriving privileges to those whose vision is likely to interfere with the safe operation of motor vehicles.(Minnesota Statutes,chapters 171.04,171.13,and 171.14;Minnesota Rule 7410.2400) All data collected on this fom is private and may not be issued to anyone,with the exception of name and address,which maybe provided to law enforcement personnel. A driver's license will not be issued until a satisfactory report is submitted. Restriction Information -For complete information see Minnesota Rule 7410.2400 ■ Daylight Restriction:Visual acuity of 20/50 or less may be restricted to daylight hours. ■ Speed Restriction:Visual acuity of 20/50 or less corrected vision in one usable eye or both eyes,or visual feld of less 20/70:45miles per hour than 105 degrees. 20/50:55 miles per hour 20/60:50 miles per hour ■ Area Restriction:Visual acuity of 20/50 or less may be restricted to driving within a certain area equal to or less thanthe speed restriction.For example,a person limited to a maximum speed of 45miles per hour or less is prohibited fromdriving on any freeway,expressway,or limited access highway that has a speed limit of more than 45 miles per hour. ■ Road Restriction:Drivers with speed restrictions may also be restricted to driving on roads that have a speed limit. ■Equipment Restriction:Field of vision less than 105 degrees in the horizontal diameter with either one usable eye orwith both eyes -requires left and right outside rearview mirrors on vehicle. MINNESOTA DRIVER'S | | | --- | LICENSE NUMBER: ## SECTION B-TO BE COMPLETED BY Date of Last Vision ExamMust have been within six months: | | | | --- | --- | | | | | --- | --- | | | | | --- | --- | □Yes,without corrective lenses Yes,with present corrective lenses Yes,with new corrective lenses Recommended Restrictions:Please mark all that apply. ## VISION PROBLEMS The condition is(please check one): STABLE□ Vision Examiner's Name: Office | | | | | | | | --- | --- | --- | --- | --- | --- | | | | | | --- | --- | --- | | | | | | --- | --- | --- | | | | | --- | --- | | | | | --- | --- | | | | | --- | --- | 1 BIRTH DATE: Phone Number( Patient's Signature(MUST be signed in the presence of the vision examiner.) Vision Acuity | | Without
Corrective Lenses | With Present
Corrective Lenses | With New
Corrected Lenses | | --- | --- | --- | --- | | Right Eye: | 20/ | 20/ | 20/ | | Left Eye: | 20/ | 20/ | 20/ | | Both Eyes: | 20/ | 20/ | 20/ | Peripheral Vision Horizontal Fields in Degree | Right Eye: | | | --- | --- | | Left Eye: | | | Both Eyes: | | Is your patient's vision adequate to exercise reasonable and proper control of a motor vehicle?(Please check one) Do you feel your patient would be safe driving in an area limited to familiar surroundings?NO□ YES□Should your patient be required to have penodic visual exams? Daylight OnlyLimit to_miles from home No Freeway DrivingOther(Spe

FAQs

Who must complete and sign each section of the Minnesota vision report?

Section A must be completed and signed by the patient in the presence of the vision examiner, while Section B must be completed and signed by a licensed vision examiner.

What information does the report collect for vision assessment?

It collects vision condition status (stable or progressive), vision acuity for right/left/both eyes (with and without corrective lenses), peripheral horizontal fields in degrees, and questions about driving safety in restricted conditions.

How is collected data used and shared under the data privacy section?

The form states the information is required by law, used by authorized Driver and Vehicle Services personnel to ensure appropriate steps are taken for insufficient vision, and that collected data is private, with an exception that name and address may be provided to law enforcement.

Oct 13, 2026

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