Driver Medical Evaluation DS 326
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This form is requested when medical information is needed to evaluate a driver's medical condition in relationship to safe driving. Primarily used by Driver Safety, this five-page document assists hearing officers to evaluate the physical and/or mental condition(s) of the driver and to determine what action, if any, to take with regard to the driving privilege.
The first page of the Driver Medical Evaluation (DME) form requires the driver to complete a brief health history and to certify under penalty of perjury that the information is true and complete. The remainder of the form requires the driver's physician to provide information on the driver's diagnosis, treatment, and level of functional impairment, if any. Specific sections address lapses of consciousness, diabetes, dementia and cognitive impairments, as they pose a higher degree of potential traffic safety risk.
Complete and sign the first page of the form and provide it to your physician to complete the remainder of the form. Also be sure to sign the medical information authorization. The DME must be signed by you and your physician, prior to being evaluated by Driver Safety.
Alternatively, medical providers with access to the Internet can print the DME, complete and sign it, and forward it to the driver. If your physician chooses to use this process, be sure that you complete the form prior to returning it to the Driver Safety office.Back to Main forms page