This document is a form for reporting a patient's vision impairment for the purpose of applying for a waiver from vision-related medical criteria to operate a school bus or Type III school bus. The report includes fields for the patient's identification, visual acuity, field of vision, color recognition, and the examiner's opinion on the patient's ability to safely perform normal required school bus operations. The form also includes fields for the examination date, physician signature date, and waiver ending date.
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