Fillable Nsw Medical Assessment Form (Page 7 of 7) in pdf

Nsw Medical Assessment Form Page 7

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Medical Assessment Form Public Passenger Vehicle Driver continued

39.

Doctor's comments (attach additional pages if required)

Note: comments on any relevant findings detected in the questionnaire or examination, making reference to the requirements of

the standards outlined in the 'Assessing Fitness To Drive' March 2012 publication.

Further pages attached

Part G – Medical Examination Certificate to be completed by Medical Practitioner ONLY

I certify that I have examined (insert applicant/driver name)

assess

suitability

for

conditional

authority,

I recommend either or both of the following actions:

Referral to an appropriate medical specialist(s)

(list specialists name(s) below)

in accordance with the relevant Commercial National

Medical Standards as set out in the publication 'Assessing

Fitness to Drive' (Commercial and Private Vehicle Drivers)

Medical Standards for Licensing and Clinical Management

Referral for a practical driving assessment by either:

Guidelines March 2012.

An accredited assessor for the type of vehicle

In my opinion the driver/applicant:

involved (taxi, private hire vehicle, bus, 4wd or

Meets the relevant criteria for an unconditional

motor cycle),

authority

An accredited driver rehabilitation centre, or

Does not meet the relevant criteria for an unconditional

specialist (eg an occupational therapist)

or conditional authority for the following reasons:

Note- Accredited assessors can be suggested by Roads

and Maritime and/or TfNSW. Any costs involved in the

assessment are the responsibility of the driver/applicant.

Medical Practitioner name (print clearly)

May meet the criteria for a conditional authority with

Medical Practitioner Signature

the following conditions:

Date

day

month

year

Catalogue No. 45071751 Form No. 1689 (03/2016) ABN 76 236 371 088

Page 7 of 7

Nsw Medical Assessment Form Page 7

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