The Nebraska DMV vision statement, printed on the form as the Statement of Vision, is a Nebraska Department of Motor Vehicles (DMV) form on which an optometrist or ophthalmologist reports the results of an applicant's eye examination. The applicant signs an authorization before the exam, and the doctor completes the medical items and signs. On FillingPDF you can fill out the form online and download or print the completed PDF. The form is published by the Nebraska DMV, and it is mailed or faxed to the DMV, not sent through this page.
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What is Vision Statement – Nebraska?
The Statement of Vision, listed by the Nebraska Department of Motor Vehicles as the Vision Statement, is a two-page form that carries an applicant's eye examination results from an optometrist or ophthalmologist to the Nebraska DMV.
The applicant completes the top section before the exam. It authorizes and requests the examining doctor to give the DMV any information about the applicant's visual condition and history, and it is dated and signed by the applicant. The doctor then certifies the examination and completes the items marked REQUIRED. These cover unaided acuity, best correctable acuity, visual acuity with telescopic and carrier lenses, the type of lenses used, the horizontal visual field in degrees, whether new corrective lenses are required, diplopia, and the date of the eye examination.
Two items apply only to commercial motor vehicle operators: question 7 on a vision condition that existed before July 30, 1996, and question 8 on color blindness. The form also asks the doctor for an opinion on how many years should pass before the applicant's vision is retested for driving purposes.
The statement is not valid after 90 days from the examination date. It is the DMV's own document, one of the forms the Nebraska DMV lists on its Forms page, and the DMV prints its mailing, fax and email details on the form.
Who needs to file Vision Statement – Nebraska?
The form is used by an applicant whose vision must be reported to the Nebraska DMV and by the optometrist or ophthalmologist who examines that applicant. The form itself does not say which license transactions call for it, so the DMV is the place to confirm whether your situation requires a Statement of Vision.
- The applicant completes the authorization at the top before the doctor's exam, adds the date and signs it.
- The optometrist or ophthalmologist certifies the exam, completes the items marked REQUIRED, and prints and signs their name, address, telephone number and fax number at the end.
- Commercial motor vehicle operators need their doctor to answer questions 7 and 8. The form says to answer them only for commercial motor vehicle operators.
The form gives no instruction for someone signing on the applicant's behalf. It asks for the applicant's signature, and the doctor signs separately.
When to file Vision Statement – Nebraska
The Statement of Vision is not valid after 90 days from the examination date, so the exam date in item 10 starts the clock. Item 10 must be completed; the form repeats the 90-day limit next to it.
The applicant signs the authorization before the doctor's exam. If you need new corrective lenses to reach the best correctable acuities listed on page 1, the form tells the doctor to delay signing until you are using the new lenses. Plan the exam and the doctor's signature so the completed form can reach the DMV within the 90 days. The form prints no other deadline.
How to fill out Vision Statement – Nebraska
Sign the applicant authorization
Before the doctor's exam, the applicant enters the date after Dated and signs on the Applicant's Signature line. This authorizes the examining doctor to give the DMV information about your visual condition and history.
Certify the examined applicant
In the certification, the doctor enters the applicant's name, street address, city, zip code, date of birth and license number.
Record unaided acuity in item 1
Enter unaided acuity for Both, Left Eye and Right Eye. Item 1 is marked REQUIRED for the optometrist or ophthalmologist.
Complete item 2 acuity entries
Enter best correctable acuity for Both, Left Eye and Right Eye in 2a. Add visual acuity using a telescopic lens (2b) and through a carrier lens (2c) as 20/ values, then mark the type of lenses used in 2d.
Enter the horizontal visual field
In item 3, enter degrees temporal and degrees nasal for the left and right eye. Add the field of vision looking through the carrier lens, temporal and nasal, for each eye.
Answer items 4 and 5
Mark Yes or No for whether new corrective lenses are required (item 4). In item 5, check highly unlikely to occur, intermittent or constant, and explain if you check intermittent or constant.
Add comments for low acuity or field
If best visual acuity is less than 20/40 in either eye or both, or the total horizontal form field is less than 140 degrees, give the cause and probable prognosis under Additional Comments (item 6).
Answer items 7 and 8 if commercial
Complete items 7 and 8 only for commercial motor vehicle operators. Item 7 asks whether a pre-July 30, 1996 condition has significantly worsened; item 8 asks whether the applicant can recognize standard red, green and amber signals.
Enter retest years and exam date
In item 9, give the number of years after which the applicant should have vision retested for driving purposes. In item 10, enter the date of eye examination, which must be completed.
Add the doctor's details and signature
Print the optometrist's or ophthalmologist's name, address, telephone number and fax number, then sign. Delay signing until new lenses are in use if they are needed to reach the listed acuities.
Review and download the completed PDF
Check the dates, signatures and required items, then download or print the completed PDF from FillingPDF and mail or fax it as described under How to submit.
How to submit Vision Statement – Nebraska
The form says that once completed it should be mailed or faxed to the Nebraska DMV. It also prints an email address.
- By mail: P.O. Box 94726, Lincoln, NE 68509.
- By fax: 402-471-4020.
- Email address printed on the form: [email protected].
Send the form while it is still valid: it is not valid after 90 days from the examination date. The form prints no fee, in-person option or status-check instructions. FillingPDF lets you fill out and download the PDF; submission follows the channels above.
Common mistakes to avoid
- Letting the doctor's exam date slip past 90 days before the form reaches the DMV; the statement is not valid after 90 days from the examination date.
- Leaving item 10, the date of eye examination, blank; the form says it must be completed.
- Skipping the applicant's date and signature in the authorization before the doctor's exam.
- Having the doctor sign before new corrective lenses are in use, when new lenses are needed to reach the best correctable acuities listed on page 1.
- Not giving the cause and probable prognosis under Additional Comments when best visual acuity is less than 20/40 in either eye or both, or the total horizontal form field is less than 140 degrees.
- Leaving questions 7 and 8 unanswered for a commercial motor vehicle operator.
- Checking intermittent or constant diplopia in item 5 without the explanation the form asks for.
- Leaving the required items, such as item 1, unaided acuity, unanswered.
Frequently asked questions
What is the Nebraska DMV vision statement?
It is the Statement of Vision, a Nebraska Department of Motor Vehicles form on which an optometrist or ophthalmologist reports an applicant's eye examination results, including acuity, visual field and diplopia. The applicant first authorizes the doctor to share the information with the DMV.
Who completes the Statement of Vision?
Two people. The applicant dates and signs the authorization at the top before the doctor's exam. The optometrist or ophthalmologist completes the items marked REQUIRED, adds the exam date and contact details, and signs.
How long is a Nebraska Statement of Vision valid?
It is not valid after 90 days from the examination date. The form states this at the top and again beside item 10, which asks for the date of eye examination and must be completed.
Where do I send the Statement of Vision?
Mail it to P.O. Box 94726, Lincoln, NE 68509, or fax it to 402-471-4020. The form also prints the email address [email protected]. Send it before 90 days pass from the exam date.
Do I answer questions 7 and 8 on the Statement of Vision?
Only if you are a commercial motor vehicle operator. The form says to answer questions 7 and 8 only for commercial motor vehicle operators. Question 7 concerns a vision condition existing before July 30, 1996, and question 8 concerns color blindness.
What if my vision is worse than 20/40 or my field is under 140 degrees?
The doctor must give the cause and probable prognosis under Additional Comments. The form requires this if best visual acuity is less than 20/40 in either eye or both, or the total horizontal form field is less than 140 degrees.
When should the doctor sign if I need new glasses?
After the new lenses are in use. The form tells the doctor to delay signing if you need new corrective lenses to reach the best correctable acuities listed on page 1.
Can I fill out the Statement of Vision online on FillingPDF?
Yes. You can fill out the PDF online on FillingPDF and download or print it. FillingPDF is an independent service and does not send the form to the Nebraska DMV; you mail or fax it using the DMV's details.
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