ATTACHMENT C - Kentucky Slide Images.pdf
PDF 151 KB Posted
- Attached to
- DDL Vision Testing Equipment
- Solicitation number
- RFB 758 2500000350 1
- Issued by
- Elliott County, Kentucky
About this file
This document is a record form for the OPTEC Vision Tester, a vision screening instrument used by the Kentucky Department of Motor Vehicles. The form is designed to document visual acuity testing results across multiple test protocols. The document contains five primary vision tests: Test #1 evaluates visual acuity for the right eye, left eye, and both eyes simultaneously using 20/40 line standards; Test #2 assesses road sign recognition and depth perception using traffic signs at varying angles of arc (323 and 145 seconds); Test #3 measures visual acuity across a range of standards from 20/100 to 20/30 for monocular and binocular vision; Test #4 evaluates muscle balance and eye coordination; and Test #5 addresses peripheral vision testing for both left and right eyes. The form includes numbered rows with color-coded slides (red, amber, and green) and corresponding digit sequences that subjects must identify during testing. Pass/fail criteria are clearly defined, with specific thresholds such as two or more incorrect responses in any group resulting in failure for that particular acuity level and eye.
The document serves as a standardized testing protocol and record-keeping tool for Kentucky DMV vision screening procedures. Test results are recorded by eye and testing condition, with sections for documenting both eyes testing, right eye testing, and left eye testing outcomes. The form includes a muscle balance assessment grid with numerical indicators representing nasal and temporal measurements at varying distances. This form represents the clinical documentation standard for Kentucky's vision testing program and appears designed to ensure consistent, objective assessment of driver vision fitness across the state.
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Text version
1000-75 RECORD FORM FOR THE OPTEC® VISION TESTER
NAME: DATE:
20/40 1 RED 6 2 6 5 3 6 8 9 3 9 62653 68939 85923 6 8 9 3 9 8 5 9 2 3
20/40 2 AMBER 9 8 3 6 2 9 3 8 2 5 98362 93825 59862 9 3 8 2 5 5 9 8 6 2
20/40 3 GREEN 2 5 9 3 8 2 5 2 9 6 25938 25296 68238 2 5 2 9 6 6 8 2 3 8
20/40 4 RED 3 9 2 6 8 3 2 5 8 5 39268 32585 36598 3 2 5 8 5 3 6 5 9 8
5 INFORMATION SIGN
6 (323 Seconds of Arc)
7 REGULATORY SIGN
8 DO NOT ENTER SIGN
9 STOP SIGN
10 RAILROAD SIGN
11 (145 Seconds of Arc)
12 NO PASSING ZONE SIGN
Which of the Road Signs appear to be closer to you?
BOTH CORRECT IS ACCEPTABLE DEPTH PERCEPTION.
20/100 1 GREEN 3 9 5 8 5 2 395 852 628 8 5 2 6 2 8
20/60 2 AMBER 9 3 2 8 5 6 8 3 9328 5683 2965 5 6 8 3 2 9 6 5
20/50 3 RED 3 5 9 6 2 6 3 8 2 9 35962 63829 85293 6 3 8 2 9 8 5 2 9 3
20/40 4 GREEN 8 9 2 3 5 9 3 5 2 8 89235 93528 65939 9 3 5 2 8 6 5 9 3 9
20/30 5 AMBER 9 2 3 5 6 5 6 8 6 9 92356 56869 26953 5 6 8 6 9 2 6 9 5 3
LEFT EYE = 20/ ____ BOTH EYES = 20/ ____ RIGHT EYE = 20/ ____
Step 1 Occlude LEFT Eye Ball Box = PASS Step 2 Ask subject if they see the box? Ball of Box = FAIL Step 3 Illuminate LEFT Eye Step 4 Ask subject if the RED ball falls IN or OUT of the box?
RIGHT PERIPHERAL TEST
LEFT PERIPHERAL TEST
Use line # (both eyes column) numbers from test # as fixation point.
TEST #1:
Two or more incorrect in any group = FAIL for that particular acuity and eye.
TEST #2:
(#6 & #11)
TEST #3:
Two or more incorrect in any group = FAIL for that particular acuity and eye.
TEST #4:
TEST #5: ° ° ° °
1000-75
VISUAL ACUITY- BINOCULAR
ACUITY LINE COLOR BOTH EYES RIGHT EYE
ROAD SIGN AND DEPTH RECOGNITION
YIELD SIGN
SCHOOL ZONE SIGN
VISUAL ACUITY- BINOCULAR
ACUITY LINE BOTH EYES RIGHT EYE
MUSCLE BALANCE - Binocular
IN
OUT
85 70 55 NASAL 45
85 70 55 NASAL 45
6 8 9 3 9 1
LEFT EYE
LEFT EYE
PASS
PASS
Denotes Stereo Depth
OPTEC VISION TESTER SLIDE 1000-75
Test #1 Visual Acuity Number Right Eye, Left Eye Monocular and Both Eyes Simultaneously (20/40)
Test #2 Road Sign and Depth Recognition Traffic Sign Identification and Depth Perception of (323 and 145 Seconds of ARC)
Test #3 Visual Acuity Number Right Eye, Left Eye Monocular and Both Eyes Simultaneously (20/100,20/60,20/50,20/40,20/30) ri Li
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Nasas
95293
Test #4 Muscle Balance
| DMV 1000-75 record form 07.2017 |
| 1000-75 KY Test Slide Image |
File details come from the government source that posted it. Updated .