Fillable Form 4319 - Driver Condition Report (Page 2 of 2) in pdf

Form 4319 - Driver Condition Report Page 2

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MEDICAL CONDITIONS

Please check

appropriate boxes if the driver being reported has any of the following conditions that would

impair his or her ability to safely operate a motor vehicle:

COGNITIVE IMPAIRMENTS/PSYCHIATRIC DISORDER

DISORDERS THAT IMPAIR CONSCIOUSNESS

(i.e., sees or hears things that are not there, gets lost easily,

(i.e., seizures, blackouts, sleep disorders)

has problems remembering words for common things,

When was the last loss of consciousness?

confusion in thought process or judgment)

_______________/ ______________/ ______________

Please explain:

(month)

(day)

(year)

Please explain:

VISUAL IMPAIRMENT

(frequently runs into objects, cannot see road signs, cannot

LIMITED MOBILITY

see objects on the side without turning head)

(i.e., paralysis, problems moving freely)

Please explain:

ALCOHOL/DRUG ABUSE

OTHER CONDITIONS

Please explain:

ADDITIONAL COMMENTS

Please attach additional comments if necessary.

Based on my observation(s) of the above named person and/or information relayed to me by the individual, I reasonably and

PERSON

in good faith, believe that he/she cannot safely operate a motor vehicle.

COMPLETING

PRINT FULL NAME (LAST, FIRST, MIDDLE)

RELATIONSHIP TO DRIVER

TELEPHONE NUMBER

FORM:

(_ _ _) _ _ _ - _ _ _ _

STREET ADDRESS

CITY

STATE

ZIP CODE

__ __ __ __ __

SIGNATURE

DATE

_ _ / _ _ / _ _ _ _

ANY PERSON WHO INTENTIONALLY FILES A FALSE REPORT SHALL BE GUILTY OF A CLASS A MISDEMEANOR, AND

SHALL BE LIABLE FOR THE DAMAGES WHICH RESULT.

MO 860-2507 (04-2010)

DOR-4319 (04-2010)

Form 4319 - Driver Condition Report Page 2

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