Nsw Medical Assessment Form Page 3
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7Medical Assessment Form Public Passenger Vehicle Driver continued
e.
How often during the last year have you failed to do what
Part C – Driver / applicant declaration – to be
was normally expected from you because of drinking?
completed by driver / applicant for authorisation
Never
Less than monthly
Privacy Statement
Monthly
Weekly
We are collecting your personal and health information in connection with your
application for a driver authority under the Passenger Transport Act 1990 and
Daily or almost daily
may retain and use it for the purposes of that Act and for driver licensing,
motor vehicle, road transport or road safety purposes. Providing this
information is voluntary but we may refuse your application unless you do so.
f.
How often during the last year have you needed a first drink
We may disclose your personal information and health information in order to
in the morning to get yourself going after a heavy drinking
verify it and to assess your application. We may disclose your personal
session?
information in respect of motor accident or other litigation enquiries and to other
public passenger transport regulators, driver licensing and vehicle registration
Never
Less than monthly
agencies. We may also disclose your personal information or health
information where relevant to accredited operators, networks, or booking or ride
Monthly
Weekly
share service providers under the Passenger Transport Act 1990 (or other
relevant legislation) and also to Transport for NSW in connection with the
Daily or almost daily
administration of any such legislation. Otherwise we will not disclose your
personal or health information without your consent unless authorised by law.
g.
How often during the last year have you had a feeling of
This Privacy Statement also applies in respect of your personal and health
guilt or remorse after drinking?
information we may subsequently collect in relation to your driver authority.
Your personal and health information will be held by Roads and Maritime
Never
Less than monthly
Services at 101 Miller St, North Sydney NSW 2060 and you have the right to
access and correct the information if you believe that it is incorrect. You can
Monthly
Weekly
contact us to request to access or correct it.
Your declaration
Daily or almost daily
I (the applicant) declare that:
•
I have read and understood all the information and questions on this
h.
How often during the last year have you been unable to
form and any other relevant medical assessment forms and my answers
remember what happened the night before because you
and the information provided by me are, to the best of my knowledge,
had been drinking?
true, correct and accurate in every detail.
Never
Less than monthly
•
I am aware that any person who attempts to obtain a driver authority by
false statement, misrepresentation or omission of details likely to affect
Monthly
Weekly
such application, shall be guilty of an offence and shall be liable to a
penalty of up to $2,200 and any authority issued may be cancelled.
Daily or almost daily
•
I will comply with the Passenger Transport Act 1990, associated
regulations and conditions relevant to a driver authority and understand
that failure to do so may result in my authority being suspended,
i.
Have you or someone else been injured as a result of your
cancelled or varied.
drinking?
•
I give authority to Roads and Maritime Services to obtain details of any
No
Yes, but not in the last year
matter which may assist in determining whether I meet the medical
criteria outline in the publication 'Assessing Fitness to Drive
Yes, in the last year
(Commercial and Private Vehicle Drivers) March 2012'.
I consent for Roads and Maritime Services to obtain any information it
requires to determine whether to grant, renew or cancel my driver authority
j.
Has a relative or friend or a doctor or other health worker
and to assess whether I am a fit and proper person of good repute, or hold
been concerned about your drinking or suggested you cut
the aptitude and responsibility to drive a public passenger vehicle. This may
down?
include (but is not limited to) complaints, charges, convictions, traffic
infringements and driver licence suspensions and cancellations (in NSW or
No
Yes, but not in the last year
elsewhere). I consent to third parties (including but not limited to police,
judiciary and licensing and other regulatory authorities) releasing that
Yes, in the last year
information to Roads and Maritime Services. This consent continues and may
not be revoked by me so long as I hold (or apply for) a driver authority or
while any legal action is proposed against me in respect of a driver authority
18.
Do you use illicit or recreational drugs?
including a suspended, cancelled or expired authority.
Yes
if yes give details
Name (print)
No
Details
Signature
19.
Have you been in a vehicle crash since your last medical
Date
examination?
/
/
month
day
year
Yes
if yes give details
No
Part D – Lodgement Details
Details
By email:
Scan this form and email to
licensing@transport.nsw.gov.au
By fax:
02 9689 8813
By mail:
Enrolment Processing Unit
Locked Bag 5085,
Parramatta NSW 2124
By hand:
Level 4,
16 - 18 Wentworth Street
Parramatta NSW 2150
Enquiries:
02 9689 8888
Catalogue No. 45071751 Form No. 1689 (03/2016) ABN 76 236 371 088
continued page 4
Page 3 of 7
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