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    Driver Safety Evaluation Form

    Uploaded by

    Kamran Rauf
    This document is a form from the Oregon Department of Motor Vehicles (DMV) that allows individuals to request that the DMV re-evaluate a driver's ability to drive safely. The form requests information about the driver in question and their observed driving behaviors that cause safety concerns. It instructs the requester to provide specific details to support why the DMV should re-evaluate the driver's license.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Driver Safety Evaluation Form

    Uploaded by

    Kamran Rauf
    84 views1 page
    This document is a form from the Oregon Department of Motor Vehicles (DMV) that allows individuals to request that the DMV re-evaluate a driver's ability to drive safely. The form requests information about the driver in question and their observed driving behaviors that cause safety concerns. It instructs the requester to provide specific details to support why the DMV should re-evaluate the driver's license.

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    This document is a form from the Oregon Department of Motor Vehicles (DMV) that allows individuals to request that the DMV re-evaluate a driver's ability to drive safely. The form requests information about the driver in question and their observed driving behaviors that cause safety concerns. It instructs the requester to provide specific details to support why the DMV should re-evaluate the driver's license.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    84 views1 page

    Driver Safety Evaluation Form

    Uploaded by

    Kamran Rauf
    This document is a form from the Oregon Department of Motor Vehicles (DMV) that allows individuals to request that the DMV re-evaluate a driver's ability to drive safely. The form requests information about the driver in question and their observed driving behaviors that cause safety concerns. It instructs the requester to provide specific details to support why the DMV should re-evaluate the driver's license.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    DMV DRIVER EVALUATION REQUEST

    DEPARTMENT OF TRANSPORTATION
    DRIVER AND MOTOR VEHICLE SERVICES
    1905 LANA AVE NE, SALEM OREGON 97314

    DMV may require re-evaluation only when there is reason to believe that a driver may no longer be qualified to hold a license.
    The individual may be required to take vision, knowledge or driving tests or obtain a medical clearance.
    INSTRUCTIONS:
    1. Complete this form to request that DMV re-evaluate a driver’s ability to drive safely.
    2. Sign this request in the signature block provided. Anonymous requests will not be honored.
    3. Mail or fax completed request to: DMV, Driver Safety Unit, 1905 Lana Avenue NE, Salem Oregon 97314; FAX: (503) 945-5329.
    NAME OF PERSON TO BE RE-EVALUATED (Last, First, Middle) SEX ODL / CUSTOMER NUMBER DATE OF BIRTH

    STREET ADDRESS CITY STATE ZIP CODE

    DRIVER BEHAVIOR – Check appropriate boxes for driving problems you have observed:
    Does not see or react to other cars, pedestrians, etc. Applies brake and gas pedals at the same time
    Drives in wrong lane or on wrong side of road Is confused by traffic
    Allows car to drift in and out of lane Gets lost or confused while driving near home
    Drives on sidewalk Backs up or changes lanes without looking back or checking mirrors
    Makes turns from wrong lane Fails to react to traffic signals, other cars, pedestrians, etc.
    Turns in front of on-coming cars Has slow reaction times (caused by medications, drugs or condition)
    Acts violently or aggressively when driving Makes driving mistakes while talking to passengers
    Drives too slowly, or stops, for no reason Falls asleep while driving
    Has trouble steering, braking, or otherwise controlling car Other actions (describe below)

    Please use the space below and the back of this form to provide specific information such as events, dates and places which cause
    you to question the individual’s ability to drive safely. If you believe the person has a medical condition/impairment that impacts safe
    driving, please provide information about its impact on their ability to safely operate a motor vehicle. Attach any supporting documentation.

     REQUESTS BASED ON AGE, DIAGNOSIS AND/OR GENERAL HEALTH ALONE WILL NOT BE HONORED. 
    Check here if you want your name kept confidential. DMV may not be able to keep this request confidential if the
    driver requests a hearing or files a lawsuit against DMV.
    YOUR RELATIONSHIP TO THE DRIVER:
    Law Enforcement Physician* Health Care Provider* (explain): _________________________________________

    Relative Friend DMV Employee Court Other (explain): __________________________________


    * Medical providers who are required to report patients under the mandatory reporting program must use DMV Form 735-7230. Please
    refer to www.OregonDMV.com for more information.
    YOUR NAME (Please Print) SIGNATURE DATE

    YOUR MAILING ADDRESS (City, State, Zip Code)


    X DAYTIME TELEPHONE NUMBER FAX

    SECTION FOR LAW ENFORCEMENT AGENCY OR COURT ONLY


    Request is a result of: Traffic Accident (attach report) Traffic Stop Date of Incident: _________________________________

    Was the driver issued a traffic citation? YES NO Citation for: _____________________________________

    Is this request submitted instead of a citation? YES NO Officer's Title: ___________________________________

    Agency name: ______________________________________________ Agency Phone: __________________________________


    735-6066 (6-15) STK # 300230

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