Form P-142OP "Eye Care Professional's Medical Report" - Connecticut

What Is Form P-142OP?

This is a legal form that was released by the Connecticut Department of Motor Vehicles - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2018;
  • The latest edition provided by the Connecticut Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form P-142OP by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form P-142OP "Eye Care Professional's Medical Report" - Connecticut

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EYE CARE PROFESSIONAL'S
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
MEDICAL REPORT
60 STATE STREET, WETHERSFIELD, CT 06161-1013
P-142OP REV. 6-2018
DRIVER SERVICES DIVISION
ct.gov/dmv
Department of Rehabilitation Services/
Driver Training Program Referral
This patient has been referred to the DMV concerning his or her ability to safely operate a motor vehicle
INSTRUCTIONS
Patient: Complete section (A).
Eye care professional (licensed physician, optometrist, ophthalmologist): complete sections (B), (C) and (D) based on the results of a personal
examination conducted within 90 days of the completion of this report. Attach other information as necessary, including any technical reports or test
results. See page 2 for vision standards.
Submission of this report to the DMV is authorized pursuant to Section 14-46 of the Connecticut General Statutes and no civil action may be brought against
any person who, in good faith, provides a report. Based upon all available information, DMV will make a final decision concerning the patient's ability to hold
an operator's license.
Section (A): Patient Information
OPERATOR'S LICENSE NUMBER
NAME (Last, First, Middle)
DATE OF BIRTH
PATIENT PHONE NUMBER
MAILING ADDRESS
(Street)
(City)
(State)
(Zip Code)
I hereby authorize and accept that my medical examiner will conduct a medical examination to determine my fitness to operate a motor vehicle safely and
may submit copies of my medical records to the DMV and/or the Department of Rehabilitation Services.
DATE
SIGNATURE OF DRIVER/PATIENT
X
Section (B): Clinical Information and Safety Implications
EXAMINATION DATE
YES
NO
Are you the regular eye care professional for this patient?
PLEASE INDICATE ANY PRESENT EYE CONDITION(S) THAT AFFECT THIS PATIENT'S ABILITY TO DRIVE SAFELY.
Based on your assessment of this patient, does the present condition prevent him or her from safely operating a motor vehicle?
YES
NO
YES
NO
Do you believe this person should be required to complete a DMV road test to determine driving ability?
DMV may require periodic reporting to ensure there has been no change in a patient's ability to drive safely. Considering this patient's condition,
should periodic reports be submitted to DMV?
YES
NO
If yes, for which condition(s) should the patient provide a report:
How often should a report be filed?
Every
months for
year(s).
Section (C): Eye-Care Specific Information
No Telescopic Lenses Permitted
Visual Acuity (SC)
RE:
LE:
OU:
Snellen (CC)
RE:
LE:
OU:
Are corrective lenses required for driving?
Does the patient have monocular vision?
YES
NO
YES
NO
If best corrected vision is 20/70 or worse, indicate cause:
Does this patient have any blind spots?
YES
NO If yes, attach visual field test results.
If both eyes are present, state uninterrupted binocular peripheral visual field in the horizontal meridian:
°
If only one eye is present, state uninterrupted monocular peripheral visual field in the horizontal meridian:
°
Does this patient have hemianopsia?
YES
NO
Is this patient color blind? (Red, green, amber)
YES
NO
Are there other conditions that should be evaluated by another medical examiner?
YES
NO
If yes, please explain:
Section D: Medical Examiner's Certification
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate
false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and
correct.
LICENSE NUMBER
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
SPECIALTY
X
TELEPHONE NUMBER
DATE
Page 1 of 2
EYE CARE PROFESSIONAL'S
STATE OF CONNECTICUT
DEPARTMENT OF MOTOR VEHICLES
MEDICAL REPORT
60 STATE STREET, WETHERSFIELD, CT 06161-1013
P-142OP REV. 6-2018
DRIVER SERVICES DIVISION
ct.gov/dmv
Department of Rehabilitation Services/
Driver Training Program Referral
This patient has been referred to the DMV concerning his or her ability to safely operate a motor vehicle
INSTRUCTIONS
Patient: Complete section (A).
Eye care professional (licensed physician, optometrist, ophthalmologist): complete sections (B), (C) and (D) based on the results of a personal
examination conducted within 90 days of the completion of this report. Attach other information as necessary, including any technical reports or test
results. See page 2 for vision standards.
Submission of this report to the DMV is authorized pursuant to Section 14-46 of the Connecticut General Statutes and no civil action may be brought against
any person who, in good faith, provides a report. Based upon all available information, DMV will make a final decision concerning the patient's ability to hold
an operator's license.
Section (A): Patient Information
OPERATOR'S LICENSE NUMBER
NAME (Last, First, Middle)
DATE OF BIRTH
PATIENT PHONE NUMBER
MAILING ADDRESS
(Street)
(City)
(State)
(Zip Code)
I hereby authorize and accept that my medical examiner will conduct a medical examination to determine my fitness to operate a motor vehicle safely and
may submit copies of my medical records to the DMV and/or the Department of Rehabilitation Services.
DATE
SIGNATURE OF DRIVER/PATIENT
X
Section (B): Clinical Information and Safety Implications
EXAMINATION DATE
YES
NO
Are you the regular eye care professional for this patient?
PLEASE INDICATE ANY PRESENT EYE CONDITION(S) THAT AFFECT THIS PATIENT'S ABILITY TO DRIVE SAFELY.
Based on your assessment of this patient, does the present condition prevent him or her from safely operating a motor vehicle?
YES
NO
YES
NO
Do you believe this person should be required to complete a DMV road test to determine driving ability?
DMV may require periodic reporting to ensure there has been no change in a patient's ability to drive safely. Considering this patient's condition,
should periodic reports be submitted to DMV?
YES
NO
If yes, for which condition(s) should the patient provide a report:
How often should a report be filed?
Every
months for
year(s).
Section (C): Eye-Care Specific Information
No Telescopic Lenses Permitted
Visual Acuity (SC)
RE:
LE:
OU:
Snellen (CC)
RE:
LE:
OU:
Are corrective lenses required for driving?
Does the patient have monocular vision?
YES
NO
YES
NO
If best corrected vision is 20/70 or worse, indicate cause:
Does this patient have any blind spots?
YES
NO If yes, attach visual field test results.
If both eyes are present, state uninterrupted binocular peripheral visual field in the horizontal meridian:
°
If only one eye is present, state uninterrupted monocular peripheral visual field in the horizontal meridian:
°
Does this patient have hemianopsia?
YES
NO
Is this patient color blind? (Red, green, amber)
YES
NO
Are there other conditions that should be evaluated by another medical examiner?
YES
NO
If yes, please explain:
Section D: Medical Examiner's Certification
I certify that I have personally examined this patient within the 90 days preceding the completion of this report. I swear or affirm under penalty of deliberate
false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, that the above information and any attachment hereto is true and
correct.
LICENSE NUMBER
MEDICAL EXAMINER'S NAME
MEDICAL EXAMINER'S SIGNATURE
SPECIALTY
X
TELEPHONE NUMBER
DATE
Page 1 of 2
EYE CARE PROFESSIONAL'S
MEDICAL REPORT
P-142OP REV. 6-2018
Health Standards for Licensing Decisions for
Operators of Motor Vehicles
Vision Standards
Minimum Physical Standards for Operators of Public Service Motor Vehicles and Service Buses Sec.
14-44-1. Minimum physical standards
(a) No person shall be issued a license for the operation of a public service motor
vehicle or service bus pursuant to section 14-44 of the General Statutes or have such license renewed unless he
first submits evidence on a form prescribed by the commissioner that he has successfully completed a physical
examination given by a licensed doctor of medicine or osteopathy except that an optometrist may perform that
portion of the medical examination which pertains to visual acuity, field of
vision and the ability to recognize colors.
(b) A person shall be deemed to have successfully passed the physical examination required in subsection
(a) of this regulation if the person.
(10) Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective
lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular
acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70‘ in the
horizontal meridian in each.
Please Note: There is no vision waiver for an operator of public service vehicles or service buses.
Sec. 14-45a-1. Vision requirements
(a) An unlimited operator's license shall be issued or retained if the applicant or license holder meets the
following visual standards:
(1) A minimum visual acuity of 20/40 (Snellen) or equivalent in both eyes or in the better eye with or without
corrective lenses;
(2) An uninterrupted binocular visual field of at least 140º in the horizontal meridian, or a monocular field of at
least 100º in the horizontal meridian; and
(3) No evidence of any other visual condition(s) which either alone or in combination will significantly impair
driving ability.
(b) A person who has a best corrected visual acuity of worse than 20/40 but at least 20/70 in the better eye,
an uninterrupted visual field of not less than 100º in the horizontal meridian, and no other visual condition(s) which
alone or in combination will significantly impair driving ability, may be issued an operator's license with vehicle
operation limited to daylight only or as otherwise determined by the commission in accordance with the provisions of
section 14-36-4 of the Regulations of Connecticut State Agencies.
(c) The commissioner may waive the provisions of subsection (a) or (b) of this section if the applicant or
license holder has a visual acuity of no worse than 20/70 (Snellen) or equivalent in the better eye with or without
corrective lenses, has an uninterrupted binocular visual field of at least 100º in the horizontal meridian, or a
monocular field of at least 70º in the horizontal meridian, has no other visual condition(s) which either alone or in
combination will significantly impair driving ability, and demonstrates to the commissioner that he or she is able to
operate a motor vehicle safely. The person's driving history and accident record shall be considered. If not
otherwise required, the commissioner may request that the person take an on-the-road driving test, and the results
of such test shall be considered in determining whether a waiver will be granted.
(d) A person who has a best corrected visual acuity better than 20/200 in the better eye, and has an
uninterrupted visual field of at least 100º in the horizontal meridian, may be issued an operator's license containing
such limitation(s) as the commissioner deems advisable after consideration of the person's vision, driving ability,
driving needs and other relevant factors including the opinion of the person's physician, ophthalmologist, or
optometrist. The person may be required to take an on-the-road driving test, and the opinion of the medical
advisory board may be requested in accordance with Sections 14-45a-10 through 14-45a-17 of the Regulations of
Connecticut State Agencies to determine whether a license shall be issued, and if so the limitation(s) that shall be
imposed.
(e) No operator's license shall be issued or retained by a person who has a best corrected visual acuity of
20/200 (Snellen) or worse in the better eye, or has an uninterrupted binocular visual field of less than 100º in the
horizontal meridian, or an uninterrupted monocular visual field of less than 70º in the horizontal meridian, or who
has any other visual condition(s) which alone or in combination will significantly impair driving ability.
(Effective April 30, 1993)
Sec. 14-45a-4. Use of telescopic aids
An operator's license shall not be issued to an operator who uses spectacle mounted telescopic aids.
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