Form SF-0257 "Vision Examination Form" - Tennessee

What Is Form SF-0257?

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

Form Details:

  • Released on January 1, 2012;
  • The latest edition provided by the Tennessee Department of Safety & Homeland Security;
  • 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 SF-0257 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Safety & Homeland Security.

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Download Form SF-0257 "Vision Examination Form" - Tennessee

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TENNESSEE DEPARTMENT OF SAFETY
AND HOMELAND SECURITY
VISION EXAMINATION FORM
Important information for Driver Applicant
The vision screening by a Driver License Examiner indicates there is a possible vision impairment that would
affect your ability to safely operate a motor vehicle. You are being asked to have your vision checked by a
licensed eye care Doctor of Optometry or Doctor of Ophthalmology to determine whether your vision can be
improved by eye glasses or eye treatment.
If you have any questions about how well you must be able to see to drive on the streets and highways of
Tennessee, the Driver’s License Examiner will be glad to assist you.
Driver License Examiners are prohibited from referring you to or recommending the name of an eye specialist.
When you return to the Driver Service Center after your eye examination, you must bring this completed form
by your eye doctor, along with any new eye glasses or corrective lenses.
FOR DOCTOR OF OPTOMETRY OR OPHTHALMOLOGY ONLY
Important information for the Eye Care Provider
All applicants for a driver license as well as drivers whose record cast doubt on their ability to drive safely, are given vision screenings by the Driver
License Examiners. When this screening indicates that a vision examination is needed by an eye care professional, the person is asked to visit a
vision specialist.
Upon completion of your eye examination of the driver applicant, please completely fill out this form and certification. Please have patient sign this
form in your presence.
No recommendations or suggestions are given by the Tennessee Department of Safety and Homeland Security Driver License Examiners as to which
eye specialist to visit. This report can only be accepted from a licensed Doctor of Optometry or Doctor of Ophthalmology.
Full Name of Person Examined
: _________________________________________________________________________________________
First
Middle
Last Name
Street Address:
City
State
Zip Code ___________
__________________________________________________________
______________________________________________
___________
ACUITY
RIGHT EYE
LEFT EYE
BOTH EYES
FIELD OF VISON
TO RIGHT OF POINT OF
WITH PRESENT
20/
20/
20/
FIXATION
GLASSES (IF ANY)
TO LEFT OF POINT OF FIXATION
20/
20/
20/
WITHOUT GLASSES
WITH BEST
TOTAL ANGLE
POSSIBLE
20/
20/
20/
CORRECTION
COLOR TEST
(OVER)
- 1 -
SF-0257 (Rev. 1/12)
RDA 1348
TENNESSEE DEPARTMENT OF SAFETY
AND HOMELAND SECURITY
VISION EXAMINATION FORM
Important information for Driver Applicant
The vision screening by a Driver License Examiner indicates there is a possible vision impairment that would
affect your ability to safely operate a motor vehicle. You are being asked to have your vision checked by a
licensed eye care Doctor of Optometry or Doctor of Ophthalmology to determine whether your vision can be
improved by eye glasses or eye treatment.
If you have any questions about how well you must be able to see to drive on the streets and highways of
Tennessee, the Driver’s License Examiner will be glad to assist you.
Driver License Examiners are prohibited from referring you to or recommending the name of an eye specialist.
When you return to the Driver Service Center after your eye examination, you must bring this completed form
by your eye doctor, along with any new eye glasses or corrective lenses.
FOR DOCTOR OF OPTOMETRY OR OPHTHALMOLOGY ONLY
Important information for the Eye Care Provider
All applicants for a driver license as well as drivers whose record cast doubt on their ability to drive safely, are given vision screenings by the Driver
License Examiners. When this screening indicates that a vision examination is needed by an eye care professional, the person is asked to visit a
vision specialist.
Upon completion of your eye examination of the driver applicant, please completely fill out this form and certification. Please have patient sign this
form in your presence.
No recommendations or suggestions are given by the Tennessee Department of Safety and Homeland Security Driver License Examiners as to which
eye specialist to visit. This report can only be accepted from a licensed Doctor of Optometry or Doctor of Ophthalmology.
Full Name of Person Examined
: _________________________________________________________________________________________
First
Middle
Last Name
Street Address:
City
State
Zip Code ___________
__________________________________________________________
______________________________________________
___________
ACUITY
RIGHT EYE
LEFT EYE
BOTH EYES
FIELD OF VISON
TO RIGHT OF POINT OF
WITH PRESENT
20/
20/
20/
FIXATION
GLASSES (IF ANY)
TO LEFT OF POINT OF FIXATION
20/
20/
20/
WITHOUT GLASSES
WITH BEST
TOTAL ANGLE
POSSIBLE
20/
20/
20/
CORRECTION
COLOR TEST
(OVER)
- 1 -
SF-0257 (Rev. 1/12)
RDA 1348
TENNESSEE DEPARTMENT OF SAFETY
VISION EXAMINATION FORM
1. Are glasses needed for distant vision? ___________________ Are they being prescribed or fitted?________________
2. Describe any irregularities such as : Double vision, poor night vision, eye injury, eye disease, poor near vision, etc:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
3. Will eye glasses improve conditions described in Question 2 above?_______________________________________
4. Will other treatments improve above-described conditions for the eyes? ____________________________________
__________________________________________________________________________________________________
5. Is the person named in this report currently undergoing the recommend treatment to improve vision? ______________
6. Additional Comments:
__________________________________________________________________________________________________
CERTIFICATION OF OPHTHAMOLOGIST OR OPTOMETRIST
I, _____________________________________________________________, being licensed to practice in the
specialty of eye care, in the State of ___________________________________, certify I have personally
examined the eyes of the above named. A true record of this examination appears on this report and he or she
signed below in my presence.
Signature of Examining Doctor ______________________________________ DATE _________________
Medical License Number ________________________________________
STATE _________________
Office Address ________________________________________________City _________________________
STATE _____________ ZIP CODE _____________Office Telephone Number ________________________
Signature of Person ____________________________________________ DATE _____________________
Receiving Eye Examination
- 2 -
SF-0257 (Rev. 1/12)
RDA 1348
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