Form DMV06-18 "Statement of Vision" - Nebraska

What Is Form DMV06-18?

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

Form Details:

  • Released on July 1, 2012;
  • The latest edition provided by the Nebraska 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 printable version of Form DMV06-18 by clicking the link below or browse more documents and templates provided by the Nebraska Department of Motor Vehicles.

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Download Form DMV06-18 "Statement of Vision" - Nebraska

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NEBRASKA DEPARTMENT OF MOTOR VEHICLES
STATEMENT OF VISION
Once completed, please mail or fax to: P.O. Box 94726 Lincoln, NE 68509
FAX: 402-471-4020
NOT VALID AFTER 90 DAYSFROM EXAMINATION DATE
___________________________________________________________________________________________________________
By this form, or copy thereof, I hereby authorize and request the examining doctor to provide any
information regarding my visual condition and history to the Department of Motor Vehicles, State of
Nebraska.
Dated:
Signed:
(Applicant’s Signature)
I hereby certify that I examined the eyes of
(Applicant’s Name)
of
(Street Address)
(City)
(Zip Code)
Date of Birth
License Number
1.
Unaided acuity: Both
Left Eye
Right Eye_________
2.
a. Best correctable acuity: Both _________ Left Eye _________ Right Eye
b. Visual acuity using telescopic lens:
20/
20/
20/
Both
Left
Right
c. Visual acuity through carrier lens:
20/
20/
20/
Both
Left
Right
d. Type of lenses used: Std. Spectacle
Aphakic
Contact Lenses
Telescopic Lenses
3.
Extent of entire horizontal form field, either binocular or monocular, as determined with a III4e
or V4e Goldmann test target or equivalent, such as the SSA Kinetic V4e isopter test on
Humphrey Field Analyzers.
Left Eye:
Degrees Temporal
Right Eye:
Degrees Temporal
Degrees Nasal
Degrees Nasal
o
o
Field of Vision looking through carrier lens:
Temp
Temp
Left
Right
o
o
Nasal
Nasal
Left
Right
Page 1 of 2
DMV 06-18/TSIE6
07/12
NEBRASKA DEPARTMENT OF MOTOR VEHICLES
STATEMENT OF VISION
Once completed, please mail or fax to: P.O. Box 94726 Lincoln, NE 68509
FAX: 402-471-4020
NOT VALID AFTER 90 DAYSFROM EXAMINATION DATE
___________________________________________________________________________________________________________
By this form, or copy thereof, I hereby authorize and request the examining doctor to provide any
information regarding my visual condition and history to the Department of Motor Vehicles, State of
Nebraska.
Dated:
Signed:
(Applicant’s Signature)
I hereby certify that I examined the eyes of
(Applicant’s Name)
of
(Street Address)
(City)
(Zip Code)
Date of Birth
License Number
1.
Unaided acuity: Both
Left Eye
Right Eye_________
2.
a. Best correctable acuity: Both _________ Left Eye _________ Right Eye
b. Visual acuity using telescopic lens:
20/
20/
20/
Both
Left
Right
c. Visual acuity through carrier lens:
20/
20/
20/
Both
Left
Right
d. Type of lenses used: Std. Spectacle
Aphakic
Contact Lenses
Telescopic Lenses
3.
Extent of entire horizontal form field, either binocular or monocular, as determined with a III4e
or V4e Goldmann test target or equivalent, such as the SSA Kinetic V4e isopter test on
Humphrey Field Analyzers.
Left Eye:
Degrees Temporal
Right Eye:
Degrees Temporal
Degrees Nasal
Degrees Nasal
o
o
Field of Vision looking through carrier lens:
Temp
Temp
Left
Right
o
o
Nasal
Nasal
Left
Right
Page 1 of 2
DMV 06-18/TSIE6
07/12
4.
Are new corrective lenses required?
Yes
No
5.
Diplopia: (Check appropriate line.)
a. highly unlikely to occur
b. intermittent*
*Please Explain:_______________________________
c. constant*
____________________________________________
6.
If best visual acuity is less than 20/40 in either eye or both, or total horizontal form field is less
than 140 degrees, give cause and probable prognosis under Additional Comments.
Answer questions #7 and #8 only for commercial motor vehicle operators.
7.
Based upon your examination, has the vision condition of this patient, which was in existence
prior to July 30, 1996, significantly worsened or another condition developed?
No
Yes
If yes, please explain:
____________________________________________________________________________
8.
Color blindness: Able to recognize the colors of traffic signals and devices showing standard
red, green and amber.
No
Yes
9.
In my opinion, this applicant should have their vision retested for driving purposes in
years.
10. Date of eye examination:
(MUST BE COMPLETED—STATEMENT OF VISION NOT VALID
AFTER 90 DAYS FROM EXAMINATION DATE.)
Additional Comments:
Name of Optometrist or Ophthalmologist
Signature of Optometrist or Ophthalmologist*
(Please Print)
Address of Optometrist or Ophthalmologist (Please Print)
Telephone Number of Optometrist or Ophthalmologist: (
)
Fax Number of Optometrist or Ophthalmologist: (
) _____________________________________
* If the applicant needs new corrective lenses to get the best correctable acuities listed on
page 1, please delay signing this statement until the new lenses are in use by the applicant.
TSIE7 07/12
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DMV06-181
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