DEPARTMENT OF MOTOR VEHICLES (DMV): California Driver License or Identification Card Number (eight characters).
Most recent episode: if this report is based upon episodic lapses of consciousness, when was the most recent episode?
Multiple episodes: if there have been multiple episodes of loss of consciousness or control within the past three years, indicate the dates if they are known to you.
While driving: within the past 12 months, has there been an episode of loss of consciousness or control while driving?
Patient: would you currently advise this patient not to drive because of his/her medical condition?
| Question | Answer |
|---|---|
| Form Name | CDPH 110c |
| Form Length | 1 page |
| Fillable? | Yes |
| Fillable fields | 101 |
| Avg. time to fill out | 17 min |
| Edition | 6/24 |
| Issuing agency | California Department of Public Health |
| Additional forms | Obtain additional forms from your local health department |
| Other names | CDPH 110c, CDPH110C, CDPH 110C, Confidential Morbidity Report, California Confidential Morbidity Report, DMV Confidential Morbidity Report |
| Official source | CDPH 110c (Rev 6/24), California Department of Public Health |
Confidential Morbidity Report Form isn’t the one you’re looking for?