Fillable Condential Eye Examination Report (Colorado DORA)

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Condential Eye Examination Report (Colorado DORA)

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The Condential Eye Examination Report (Colorado DORA) form is 2 pages long and contains:

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  • 13 check-boxes
  • 52 other fields

Country of origin: US
File type: PDF

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Colorado Department of Regulatory Agencies (DORA) is responsible for professional licensing and consumer protection in Colorado USA.

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Page 1 of 2
Driver/Patient Section
Patient Last Name First Name Middle Initial
Street Address City State ZIP
Customer Identication Number (CIN) Date of Birth
Driver Statement of Understanding (Driver signature not required for DMV processing):
• My Physician/Ophthalmologist/Optometrist will conduct an eye examination to determine my tness to operate a
motor vehicle safely and responsibly.
• My Ophthalmologist/Optometrist will respond to any additional questions from the Department of Motor Vehicles
(DMV).
• I understand that this form will be considered in any decision regarding the issuance of my driver license,
pursuant to C.R.S. 42-2-111 & 42-2-112.
Signature of Driver or Patient Date (MM/DD/YY)
Ophthalmologist/Optometrist/Physician Section
Instructions: use your best clinical judgment as you REVIEW AND COMPLETE ALL SECTIONS. Base severity ratings within each category on
your overall assessment of impairment relative to the driving task. Form must be completed by the Physician (MD or DO) or OD. Pursuant to C.R.S. 42-
2-112, no civil or criminal actions shall be brought against any physician, physician's assistant, or optometrist based in Colorado for providing a medical
opinion if the physician, physician's assistant, or optometrist acts in good faith and without malice.
Colorado Vision Recommendations – 20/40 or better in either eye with or without corrective lenses, and total combined horizontal eld of
vision, with both eyes, of at least 120 degrees, or if blind in one eye, at least 60 degrees in the other eye. If best visual acuity with or without corrective
lenses is worse than 20/100 in the carrier lenses, the bioptic telescope must correct the visual acuity to at least 20/40.
Examination Information (check all that apply and please do not abbreviate)
Applicant is currently being treated for one or more of the following progressive ocular condition(s):
Macular Degeneration
Retinitis Pigmentosa
Glaucoma
Visual Field Decit
Other
N/A
Does patient have visual eld decit which makes driving unsafe?
Yes
No
Additional Information
Distance Acuity Right Left Both
With Correction 20 / 20 / 20 /
Without Correction 20 / 20 / 20 /
Bioptic Lens 20 / 20 / 20 /
Horizontal Perception Fields
Left:
Pass Decient Fail
Right:
Pass Decient Fail
DR 2402 (09/03/20)
COLORADO DEPARTMENT OF REVENUE
Division of Motor Vehicles
P.O. Box 173350
Denver CO 80217-3350
FAX: (303) 205-8301
Condential Eye Examination Report
(Continued on next page)
Page 2 of 2
DR 2402 (09/03/20)
Need DMV Re-Examination in one year? Yes No
Examination Date (mm/dd/yyyy)
Form is valid for 180 days from date of exam
Patient Last Name First Name Middle Initial
Based on my observations of this patient and information relayed to me by this individual, I, reasonably and in good faith, believe that
_______________________________________________________________________is:
Patient Name
Specialty (Required) License Number (Required) Phone Number (Required)
Street Address City State ZIP
Physician Name (Printed) Signature (Required)
Recommended license restriction(s):
Daylight Driving Only
No Highway/Freeway Driving
Mile Radius Only ________
Restricted MPH _________
Bioptic Lens
Automatic Transmission Only
Other
_________________________
Fit to operate a motor vehicle safely.
Fit to operate a motor vehicle safely contingent upon passing a DMV Road Test.
NOT FIT to operate a motor vehicle safely and responsibly due to signicant
medical-functional compromise or decit.
Fitness to drive determination pending; rehab permit required
Patient also requires a Medical Exam
Must
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Condential Eye Examination Report (Colorado DORA)

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Completed 22 April 2022

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