Fillable Form MAB103 RMV CDL Vision Screening Certificate

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Form MAB103 RMV CDL Vision Screening Certificate

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The Form MAB103 RMV CDL Vision Screening Certificate form is 2 pages long and contains:

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CDL Vision Screening Certificate
p.1 MAB103_0118
Applicants for class A, B, or C learner’s permits or licenses may use this form. This form must be completed by an ophthalmologist or by an optometrist
who is licensed to practice in the Commonwealth of Massachusetts.
Minimum required visual standards for CDL as described by Federal Motor Carrier Safety Administration
49 CFR §391.41 Physical qualifications for drivers
“Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or
better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least
70º in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber;”
Monocular drivers are not qualified.
A. Applicant Information
Last Name
First Name
Middle Name
Suffix
Massachusetts Driver’s License #
Phone #
I hereby authorize the ophthalmologist or optometrist completing this form to discuss its content with representatives of the Registry of Motor Vehicles.
Signature: ________________________________________________________________________ Date: __________________________
B. Vision Screening Data
1. Visual Acuity (Snellen) Without RX With RX
Right Eye (OD) 20/___ 20/___
Left Eye (OS) 20/___ 20/___
Both Eyes (OU) 20/___ 20/___
Do NOT use qualifiers such as + or – symbols, or the counting fingers (“CF”) designation to indicate visual acuity.
2. T
otal Horizontal Visual Field – Both Eyes Combined: ___________ (Record in Degrees).
**Suggested Target size to be used: 10mm
3. Are glasses and/or contact lenses needed for driving? ......................................................................................................................... Yes No
If yes, Question #1 should indicate visual acuity “With RX”
4. Is the applicant’s vision characterized by Unresolved Diplopia?. ........................................................................................................... Yes No
NOTE: To obtain a license, “No” must be checked in Question # 4.
5. Can the applicant distinguish red, green, and amber colors? ................................................................................................................ Yes No
NOTE: To obtain a license, “Yes” must be checked in Question # 5.
Listed below are the conditions, treatment, or medication plan which the applicant must follow in order to maintain the validity of my professional
opinion:
_______________________________________________________________________________________________________________________
A license is valid for five (5) years. Do you think that the applicant should be re-evaluated by the Registry during that time period? ........ Yes No
If “YES,” please complete:
“I recommend a re-evaluation on __________ (month/year) due to __________________________________________________ (condition/ disease)
and _______________________________________________________________________________________________ (other factors/comments).”
Turn over to complete reverse side
p.2 MAB103_0118
Provided said applicant follows the conditions and treatment prescribed on this certificate, in my professional opinion the operator meets the minimum
visual standards required by the Federal Motor Carrier Safety Administration (described above) and therefore is visually qualified to safely operate
commercial vehicles.
Yes No
I, the undersigned ophthalmologist or optometrist, agree to keep a copy of this Vision Screening Certificate in my office for a one-year period following
the date of the screening. I hereby certify that the information provided herein is true, accurate, and complete.
Ophthalmologist or Optometrist Name
Massachusetts Registration #
Date of Screening (MM/DD/YYYY)
Office Phone #
Check One
M.D.
O.D.
Ophthalmologist or Optometrist Signature: _____________________________________________________ Date: ________________________
NOTE: The Registry will not accept this certificate after twelve months from date of screening.
A photocopy of the certificate will not be accepted. Only a certificate with original writing will be accepted.
Please be advised that Massachusetts may waive the federal visual standards for INTRASTATE commerce if the individual has a combined horizontal
peripheral field of vision of not less than 120 degrees; provided the individual also has a distant visual acuity of at least 20/40 (Snellen) in either eye,
with or without corrective lenses, and the ability to distinguish the colors red, green, and amber. The federal government also has a vision exemption
program for INTERSTATE driving. To learn more about the federal program, visit their website at http://www.fmcsa.dot.gov/rules-
regulations/topics/medical/exemptions.htm
To Be Completed by RMV Personnel Only
Reviewed at: _____________________________ Office On: ________________________ By: __________________________________________
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Form MAB103 RMV CDL Vision Screening Certificate

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Completed 18 February 2020

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