Employer s Report of Medical Exam Failure Request for Reexamination of Driver DS 524

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This form is to be completed and used by employers for the following:

  • Reporting class A or B drivers who fail to qualify for a medical certificate or,
  • Requesting the Department of Motor Vehicles (DMV) investigate the qualifications of any driver whose condition or behavior may impair his or her ability to safely operate a motor vehicle.

When completing this form:

  1. Complete all identifying information for the driver you are reporting: (name, birthdate, license number, class of license, state issuing license, address, city, state, zip code, and telephone number).
  2. Complete all employer information.
  3. If reporting a class A or B driver who fails to qualify for a medical certificate, in addition to providing the identifying information for the driver, it is also necessary for you to complete the information regarding the physician.
  4. If requesting that a driver be reexamined by DMV, in addition to providing the identifying information of the driver, it is also necessary for you to supply a description of the condition or actions of the driver which lead you to believe he or she may pose a risk to traffic safety.
  5. A signature, title, and date are required before DMV will be able to process this request.
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