2010 BC Guide in Determining Fitness to Drive

21.19 Visual field test form (VFT)VISUAL FIELD TESTPaid for by the Office of the Superintendent of Motor Vehicles through theMSP Billing System (see form back)OPTOMETRISTSMSP Fee Code 96225PERSONAL HEALTH NUMBER(MUST BE COMPLETED)The personal information on this form is collected under the authority of the Motor Vehicle Act, Medicare Protection Act, and theFreedom of Information and Protection of Privacy Act. The information provided will be used to determine your fitness to drivea motor vehicle and allow the physician to bill through the British Columbia Medical Services Plan for the service. Personalinformation is protected from unauthorized use and disclosure in accordance with the Freedom of Information and Protection ofPrivacy Act and may be disclosed only as provided by that Act. If you have any questions about the collection, use anddisclosure of the information collected, contact the Office of the Superintendent of Motor Vehicles at (250) 387-7747.THIS REPORT MUST BE COMPLETED IN FULL BY AN OPTOMETRIST AND RETURNED WITHIN 30 DAYS TO THEOFFICE OF THE SUPERINTENDENT OF MOTOR VEHICLESDriver’s Name:DL#:Date Issued:Licence Class:Date of Birth:Reason For This Examination: This person has been referred to determine if he/she meets the vision guidelines for the class ofdriver’s licence indicated above.VISUAL FIELD TEST (VFT)For drivers with visual field deficits, one of the following techniques should be documented andthe visual field printout attachedBINOCULAR TESTING IS REQUIREDClass 5-8 drivers require testing to 120 degrees of horizontal vision.Class 1-4 drivers require testing to 150 degrees of horizontal vision. Goldmann, Esterman, and Humphreys 135 are the onlytests that will provide testing to 150 degrees.1. Goldmann III4e and V4e isopters2. Humphrey Esterman test3. Humphrey 81, 120, 135, or 246 point screener. If field is abnormal, set test strategy to 3 zone and all other parameters tostandard. Two zone Humphrey testing is inadequate.4. Medmont 700 Driving Field using the numeric grid format. Studio format is NOT ACCEPTABLE.EXAMINING OPTOMETRIST’S NAME AND ADDRESS(Use Rubber Stamp or Print)EXAMINATION DATE(YYYY/MM/DD)SIGNATURE OF EXAMINING OPTOMETRISTTELEPHONE NUMBER:284