What the 5109 is for
The Vision Report tells the Registrar of Motor Vehicles that a patient has, or appears to have, a visual impairment that may make driving dangerous. Optometrists report only visual conditions, and the 5109 is the form MTO asks them to use. Physicians and nurse practitioners report the same impairments on the Medical Condition Report, Form 5108.
Section A is the mandatory report under section 203(1) of the Highway Traffic Act. Section B is the discretionary report under section 203(2).
Who completes it
The optometrist completes the whole form, including Part 3 with their licence number and signature. The patient completes nothing.
How to fill in the report
Part 1, Patient Information
Enter the name, date of birth, address and gender, and the driver’s licence number if available. Starred fields are mandatory.
Part 2, Section A, Mandatory Report
Tick the condition that applies: best corrected acuity below 20/50 with both eyes open and examined together, a visual field below the printed limits including hemianopia, or diplopia within 40 degrees of fixation that prisms or patching can’t correct. Record acuity with and without correction for each eye and both eyes, field degrees for each eye and both eyes together, and the diagnosis.
Part 2, Section B, Discretionary Report
Use this when the patient doesn’t meet a mandatory threshold but has a visual condition that, in your opinion, may make driving dangerous. Describe the condition and its effect on driving.
Measuring the field
Page two sets the rules MTO applies. Measure without devices that enhance or modify vision, such as telescopic or prism lenses. The blind spot doesn’t count toward the continuous field, and at least half of the required horizontal degrees must lie on each side of the vertical meridian.
Common reasons it’s delayed
- Acuity entered without stating whether it was with or without correction.
- Field results given for one eye only when the standard is both eyes examined together.
- Both Section A and Section B completed for the same finding.
- Missing licence number, signature or date in Part 3.
Submitting and who pays
Mail or fax the form to the Driver Medical Review Office at the address and fax numbers printed on it. If you fax it, don’t also mail the original.