Form BMV6317 "Vision Screening Referral" - Ohio

What Is Form BMV6317?

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

Form Details:

  • Released on October 1, 2019;
  • The latest edition provided by the Ohio Department of Public Safety;
  • 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 BMV6317 by clicking the link below or browse more documents and templates provided by the Ohio Department of Public Safety.

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Download Form BMV6317 "Vision Screening Referral" - Ohio

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OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
VISION SCREENING REFERRAL
Preliminary vision screening indicates that you may not meet Ohio’s vision standards to renew your driver license per Ohio Revised
Code (R.C.) sections 4507.12 and 4506.09. NOTE: A hold will be placed on your driver license and you will not be able to legally drive
a motor vehicle until you meet vision standards required for licensing.
In order to obtain an Ohio driver license, you may go to a driver license exam station for further vision testing, or visit an
ophthalmologist or licensed optometrist of your choice who shall conduct a vision screening and certify the results on this form.
Return the completed form, within 30 days, to a deputy registrar license agency to verify whether vision screening results
meet vision standards required for licensing.
LAST NAME (PRINTED)
FIRST NAME (PRINTED)
MIDDLE INITIAL (PRINTED)
LICENSE NUMBER
CLASS
DX CUSTOMER KEY NUMBER
I hereby authorize and request information regarding my visual condition be released to the Special Case Unit, Bureau of Motor Vehicles.
APPLICANT SIGNATURE
DATE
X
DEPUTY REGISTRAR VISION SCREENING RESULTS
DRIVER EXAM STATION VISION SCREENING RESULTS
ACUITY
HORIZONTAL FIELD
ACUITY
HORIZONTAL FIELD
Right
Left
Both
Right
Left
Right
Left
Both
Right
Left
WITHOUT
20/
20/
20/
TEMP
20/
20/
20/
TEMP
LENSES
20/
20/
20/
NAS
20/
20/
20/
NAS
WITH
LENSES
Date
Unit
Date
Unit
VISION SPECIALIST:
R.C. 4507.12 requires that driver license applicants pass a vision screening before obtaining a driver license.
When unable to pass, they are asked to visit an ophthalmologist or licensed optometrist for an examination to determine if their vision
can be improved sufficiently to qualify for a license. PLEASE COMPLETE THIS FORM AND RETURN TO APPLICANT AFTER EXAM.
1.
VISUAL
PRESENT ACUITY
ACUITY WITH NEW CORRECTION
ACUITY
Right
Left
Both
Right
Left
Both
20/
20/
20/
WITHOUT
20/
20/
20/
LENSES
20/
20/
20/
WITH
LENSES
2.
VISUAL
Does the applicant have a normal visual field in each eye as screened
Visual Field
Right Eye
Left Eye
If
FIELD
by standardized techniques?
Yes
No,
"No" please provide
Temporal
Degrees
Degrees
the peripheral extent of the visual field measured by using a 10 mm
Nasal
Degrees
Degrees
white target.
3.
Except for normal deterioration due to aging, does the applicant have a progressive visual deficiency?
Yes
No, If "YES", please describe condition
Due to this condition, is it necessary for the Bureau of Motor Vehicles to require yearly vision screenings?
Yes
No
4.
COLOR
Did the applicant (commercial drivers only) pass the color vision test (Farnworth D-15)?
Yes
No
VISION
VISION SPECIALIST CERTIFICATION – The information that I have provided is based upon my examination of the person named hereon.
VISION SPECIALIST NAME (PRINTED)
VISION SPECIALIST SIGNATURE
DATE
X
BUSINESS ADDRESS (STREET)
CITY
STATE
ZIP CODE
CERTIFICATION / LICENSE NUMBER
TELEPHONE NUMBER
(
)
BMV 6317 10/19 [760-0310]
OHIO DEPARTMENT OF PUBLIC SAFETY
BUREAU OF MOTOR VEHICLES
VISION SCREENING REFERRAL
Preliminary vision screening indicates that you may not meet Ohio’s vision standards to renew your driver license per Ohio Revised
Code (R.C.) sections 4507.12 and 4506.09. NOTE: A hold will be placed on your driver license and you will not be able to legally drive
a motor vehicle until you meet vision standards required for licensing.
In order to obtain an Ohio driver license, you may go to a driver license exam station for further vision testing, or visit an
ophthalmologist or licensed optometrist of your choice who shall conduct a vision screening and certify the results on this form.
Return the completed form, within 30 days, to a deputy registrar license agency to verify whether vision screening results
meet vision standards required for licensing.
LAST NAME (PRINTED)
FIRST NAME (PRINTED)
MIDDLE INITIAL (PRINTED)
LICENSE NUMBER
CLASS
DX CUSTOMER KEY NUMBER
I hereby authorize and request information regarding my visual condition be released to the Special Case Unit, Bureau of Motor Vehicles.
APPLICANT SIGNATURE
DATE
X
DEPUTY REGISTRAR VISION SCREENING RESULTS
DRIVER EXAM STATION VISION SCREENING RESULTS
ACUITY
HORIZONTAL FIELD
ACUITY
HORIZONTAL FIELD
Right
Left
Both
Right
Left
Right
Left
Both
Right
Left
WITHOUT
20/
20/
20/
TEMP
20/
20/
20/
TEMP
LENSES
20/
20/
20/
NAS
20/
20/
20/
NAS
WITH
LENSES
Date
Unit
Date
Unit
VISION SPECIALIST:
R.C. 4507.12 requires that driver license applicants pass a vision screening before obtaining a driver license.
When unable to pass, they are asked to visit an ophthalmologist or licensed optometrist for an examination to determine if their vision
can be improved sufficiently to qualify for a license. PLEASE COMPLETE THIS FORM AND RETURN TO APPLICANT AFTER EXAM.
1.
VISUAL
PRESENT ACUITY
ACUITY WITH NEW CORRECTION
ACUITY
Right
Left
Both
Right
Left
Both
20/
20/
20/
WITHOUT
20/
20/
20/
LENSES
20/
20/
20/
WITH
LENSES
2.
VISUAL
Does the applicant have a normal visual field in each eye as screened
Visual Field
Right Eye
Left Eye
If
FIELD
by standardized techniques?
Yes
No,
"No" please provide
Temporal
Degrees
Degrees
the peripheral extent of the visual field measured by using a 10 mm
Nasal
Degrees
Degrees
white target.
3.
Except for normal deterioration due to aging, does the applicant have a progressive visual deficiency?
Yes
No, If "YES", please describe condition
Due to this condition, is it necessary for the Bureau of Motor Vehicles to require yearly vision screenings?
Yes
No
4.
COLOR
Did the applicant (commercial drivers only) pass the color vision test (Farnworth D-15)?
Yes
No
VISION
VISION SPECIALIST CERTIFICATION – The information that I have provided is based upon my examination of the person named hereon.
VISION SPECIALIST NAME (PRINTED)
VISION SPECIALIST SIGNATURE
DATE
X
BUSINESS ADDRESS (STREET)
CITY
STATE
ZIP CODE
CERTIFICATION / LICENSE NUMBER
TELEPHONE NUMBER
(
)
BMV 6317 10/19 [760-0310]