MPO-211 (3/2018)
MUNICIPAL POLICE OFFICERS’ EDUCATION AND TRAINING COMMISSION
8002 Bretz Drive
Harrisburg, Pennsylvania 17112-9748
http://www.psp.pa.gov/MPOETC
VISION EXAMINATION
This form is to be used by both municipal police officer applicants and police academy cadet applicants.
THIS EXAMINATION MUST BE ADMINISTERED by a licensed optometrist or ophthalmologist who is licensed in Pennsylvania. This examination is to
determine the physical fitness, specifically related to specific vision standards, of the applicant to be certified as a police officer in Pennsylvania. The
applicant who you are about to examine is applying for certification and will be vested with a position of public trust.
LAST NAME FIRST NAME MIDDLE INITIAL
STREET ADDRESS
CITY/BORO STATE ZIP CODE
SOCIAL SECURITY NUMBER
DATE OF BIRTH GENDER DATE OF EXAM
VISION: The applicant must have vision of at least 20/70, uncorrected, in the stronger eye, correctable to 20/20; and at least 20/200, uncorrected, in
the weaker eye, correctable to at least 20/40; have normal depth perception and color vision, and must be free of any significant visual abnormality.
RIGHT EYE UNCORRECTED 20/_____ LEFT EYE UNCORRECTED 20/_____
CORRECTED 20/_____ CORRECTED 20/_____
Does the applicant have normal depth perception? (Stereopsis >48% or Arc Seconds <100) YES NO
Does the applicant have normal color perception? (Farnsworth or Ishihara) YES NO
Is the applicant free from any other significant visual abnormalities? YES NO
THE APPLICANT SHOULD BE MARKED “CAPABLE” IN THE BLOCK BELOW ONLY IF VISION MEETS ALL STATED REQUIREMENTS
PROFESSIONAL OPINION
PHYSICALLY CAPABLE (VISION) - I have examined the applicant, and it is my professional opinion that the person named above meets the
vision standards which are described above and required to perform the duties a certified police officer in Pennsylvania.
PHYSICALLY UNFIT (VISION) - I have examined the applicant, and it is my professional opinion that the person named above does not meet
the vision standards which are described above and required to perform the duties a certified police officer in Pennsylvania.
I hereby certify that the information and statements contained in the tables above and in the attached examination report are true and correct, and
that I am signing this document with the full understanding that any false information or statement will subject me to criminal penalties of Title 18,
Crimes code, Section 4904, relating to unsworn falsification to authorities.
This examination form must be forwarded to the employing police department, certified Act 120 police academy, or MPOETC by the optometrist or
ophthalmologist within 15 days of the date of examination, even if the applicant is found physically unfit, pursuant to 37 Pa. Code § 21.11(4)(iv).
SIGNATURE – PENNSYLVANIA LICENSED OPTOMETRIST/OPHTHALMOLOGIST DATE
OPTOMETRIST/OPHTHALMOLOGIST NAME (PRINTED) LICENSE NO. TELEPHONE NO.
STREET ADDRESS CITY/BORO STATE ZIP CODE
RELEASE OF PHYSICAL INFORMATION
Having applied for certification/training as a police officer in Pennsylvania and having subjected myself to a vision examination by a licensed
optometrist or ophthalmologist, as required by the Act, I reserve the right to have the data and conclusions of the physician remain confidential except
to those whom I designate. Accordingly, I hereby authorize the optometrist or ophthalmologist named above to release all information related to my
vision examination to the Municipal Police Officer’s Education and Training Commission (MPOETC) AND to any additional police departments and/or
academies listed below, for purposes consistent with the application process pursuant to this Act. No other release of this information, explicit or
implied, is granted at this time.
____________________________________________________________________________
NAME OF MUNICIPAL POLICE DEPARTMENT AND/OR CERTIFIED ACT 120 ACADEMY (Print)
_______________________________________________________________________________________________________________________________________________________________
ADDRESS CITY STATE ZIP CODE FAX EMAIL
SIGNATURE – APPLICANT DATE
