Nsw Medical Assessment Form

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Medical Assessment Form
Public Passenger Vehicle Driver
Important information
Roads and Maritime Services must be able to attest that all drivers of public passenger vehicles are fit and proper persons to hold an authority
to drive such vehicles. This information is being collected in order to determine your fitness to drive a public passenger vehicle under the
Passenger Transport Act 1990 and Passenger Transport Regulation 2007. If Roads and Maritime cannot attest to you being a fit and proper
person to hold an authority, the authority may be suspended, varied or cancelled or your application for authorisation may be refused.
You have a right to request access to the information collected by contacting Roads and Maritime, the contact details are at the end of this
form. Roads and Maritime may disclose any health information received to a medical practitioner and/ or specialist.
If you are lodging this as part of your taxi-cab or private hire vehicle driver authority and you are under 60 years of age, you need to
complete Medical Assessment Form Private Hire Vehicle and Taxi-cab Drivers – Form 1799
Make an appointment with your doctor. As the examination may take longer than a routine consultation, please advise the
receptionist when making the appointment that you are attending for this purpose.
If you wear spectacles, hearing aids etc, please take them with you to the examination.
Complete Parts A and B of this form, including signing the Declaration/Consent (Part C), and take it with you to the appointment so
the doctor can complete Parts E, F and G.
You are required by the Passenger Transport Regulation 2007 to advise Roads and Maritime of any condition that may affect your
ability to drive a public passenger vehicle. You should make the doctor aware of any medical condition/s you have so that your
doctor can advise Roads and Maritime, on your behalf using this form.
If the medical assessment/report has been requested for a particular reason, you should let your practitioner know this reason.
On completion of the examination the doctor will complete Parts E, F and G of this form, after which you should return the whole
form to Roads and Maritime. (Refer to Part D for lodgement details)
Payment for any medical examination is the responsibility of the authority holder/applicant.
Part A – Driver Details – to be completed by driver /
Part B – Medical Questionaire – to be completed by
applicant for authorisation
driver / applicant for authorisation
1.
Surname (family name)
Please answer the questions by ticking the correct box and
supplying details (if applicable). If you are not sure, leave the
question blank and ask your Medical Practitioner (doctor) what it
means. You must then answer the question with your doctor.
2.
Given names
Your doctor will also ask you additional questions during the
examination.
11.
Are you being treated for any illness or injury?
Yes
if yes give details
3.
4.
Date of birth
Sex
Male
No
/
/
Female
day
month
year
Details
5.
Residential address (PO box not accepted)
Postcode
6. a
Contact phone number
b
Mobile number
12.
Are you taking any medications (either prescribed by your
doctor or otherwise)?
Yes
if yes give details
7.
Driver licence number
No
Condition(s)
List medications currently
medications are taken for
being taken for condition(s)
8.
Authority number
9.
Authority status
Current
Not Current
10.
Authority type
Bus
Taxi
Motorcycle
Private Hire Vehicle
4WD
continued page 2
Enrolment Processing Unit
Level 4, 16 - 18 Wentworth Street Parramatta NSW 2150
Locked Bag 5085, Parramatta NSW 2124
1800 227 774
T 02 9689 8888
F 02 9689 8813
E licensing@transport.nsw.gov.au
Catalogue No. 45071751 Form No. 1689 (03/2016) ABN 76 236 371 088
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