The Tennessee Drivers License form is a crucial document that ensures applicants meet the necessary vision standards to operate a vehicle safely. This form requires a vision examination by a licensed eye care professional, who will assess whether corrective lenses or treatment are needed. If you are ready to proceed with your vision examination, please fill out the form by clicking the button below.
When applying for a driver's license in Tennessee, one crucial component is the Vision Examination Form, which serves as a key step in ensuring that applicants can safely operate a motor vehicle. This form is designed to assess an individual’s visual acuity and overall eye health, particularly if initial screenings by Driver License Examiners indicate potential vision impairments. The process begins with a vision screening, and if any concerns arise, the applicant is required to consult a licensed eye care professional—either an optometrist or an ophthalmologist. After the examination, the eye care provider must complete the form, documenting the findings and any necessary corrective measures, such as glasses or treatments. Importantly, the form must be signed by both the eye doctor and the applicant, confirming that the examination took place. It’s essential for applicants to bring this completed form back to the Driver Service Center along with any prescribed corrective lenses. The Vision Examination Form not only helps maintain road safety but also ensures that drivers are equipped with the necessary vision capabilities to navigate Tennessee's streets and highways effectively.
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: _________________________________________________________________________________________
FirstMiddleLast Name
Street Address: __________________________________________________________ City ______________________________________________ State ___________ Zip Code ___________
ACUITY
RIGHT EYE
LEFT EYE
BOTH EYES
FIELD OF VISON
WITH PRESENT
TO RIGHT OF POINT OF
20/
FIXATION
GLASSES (IF ANY)
TO LEFT OF POINT OF FIXATION
WITHOUT GLASSES
WITH BEST
TOTAL ANGLE
POSSIBLE
CORRECTION
COLOR TEST
SF-0257 (Rev. 1/12)
(OVER)
- 1 -
RDA 1348
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
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