Dld 134 Form PDF Details

The DLD 134 form, also known as the Functional Ability Evaluation Medical Report, is an essential document for individuals seeking to apply for or renew driving privileges in Utah. It plays a pivotal role in ensuring the safety of both the applicant and the public by assessing the physical, mental, and emotional health of the driver. The form requires the applicant to provide detailed personal information, including their name, address, social security number or ITIN, and any changes to their residential or mailing address. Moreover, applicants must disclose any health conditions or medications that could affect their driving ability, such as heart conditions, use of alcohol or drugs, psychiatric conditions, visual impairments, seizures, and more. This comprehensive evaluation extends to the healthcare professional's perspective, who must fill out a functional ability profile based on current standards and guidelines, indicating any recommended restrictions or necessary tests. The DLD 134 form emphasizes the collaborative effort between the applicant, healthcare professionals, and the Utah Driver License Division to maintain road safety while addressing the individual needs of drivers.

QuestionAnswer
Form NameDld 134 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdld 134 form, dld 134 rev 5 18, utah, DST

Form Preview Example

FUNCTIONAL ABILITY EVALUATION MEDICAL REPORT

UTAH DRIVER LICENSE DIVISION

TOP PORTION MUST BE COMPLETED BY APPLICANT - Please use BLACK ink

P O BOX 144501

Fax Number: 801 957-8698

www.driverlicense.utah.gov

SLC UT 84114-4501

(801) 957-8690

 

 

_______________________________________________________________________________________________________________________________________

Last NameFirst NameMiddle or Maiden NameDate of BirthDriver License or Driving Privilege Card Number

_______________________________________________________________________________________________________________________________________

Street AddressCityStateZip CodeSocial Security Number / ITIN

________________________________________________________________________________________________________________________________________

Mailing Address

City

State

Zip Code

If either your residential or mailing address has changed, please mark the box and print the new address above.

By submitting this change of address, I affirm, under penalty of law, that this is my true and correct Utah residence address and/or mailing address.

If you have a commercial driver license, you will need to appear at a commercial driver license office to obtain a new license with your correct address within 10 days. As part of my application for driving privileges, the following information about my physical, mental and emotional health is submitted. Report below anything which might affect driving, such as heart attacks, use of alcohol or other drugs, psychiatric conditions, accidents, visual loss, etc. If you experience seizures, please give date(s) of the last occurrence(s). Also, please list any medications being used for any medical conditions: _______________________________________________________

_______________________________________________________________________________________________________________________________________

By signing this form, I authorize my healthcare professional(s) to disclose specific health information regarding my physical, mental and emotional condition relevant to my ability to safely operate a motor vehicle, to the Utah Driver License Division, P.O. Box 144501, Salt Lake City, Utah 84114-4501. This authorization is valid for five years or the period of time needed to fulfill its purpose, whichever comes first. I also understand that I may revoke this authorization at any time, by sending written notification to the Utah Driver License Division at the above address.

I understand that if I fail to sign this authorization my driving privilege may be affected. I understand that this information will be classified as a private record in accordance with GRAMA (UCA 63G-2-202). Individuals who are entitled to have a “private” record disclosed to them are limited to the subject of the record, a parent or legal guardian of an unemancipated minor or legally incapacitated individual, an individual with power of attorney or a notarized release signed by the subject of the record, or an individual with a court or legislative subpoena.

APPLICANT’S SIGNATURE:__________________________________________________________________________ Date: ______________________________

Form will not be processed without signature

HEALTH CARE PROFESSIONAL REPORT

The following functional ability profile is for use in determining driving privileges. It is consistent with the current edition of Functional Ability in Driving: Guidelines and Standards for Health Care Professionals. Please indicate profile below with a check mark, your initials or an “X” to show appropriate level for each category.

Profile Level

1

2

3

4

5

6

7

8

A

Diabetes

&

Metabolic

Condition

K

No Driving

B

Cardio-

Vascular

&

High Blood

Pressure

S D A *

No Driving

C

Pulmonary

Inhaler Only

Oxygen w/Driving

K

S D A *

No Driving

D

Neurologic

K

DST

No Driving

E

Seizures

or

Episodic

Conditions

K MAB C

No Driving

F

Learning Memory

K

Not Used

DST/S D A *

No Driving

G

Psychiatric

or

Emotional

Condition

K

No Driving

H

Alcohol &

Other

Drugs

K

S D A *

No Driving

J

Musculo-

skeletal/

Chronic

Debility

K MAB C

DST

DST

DST

No Driving

K

Alertness

or

Sleep

Disorders

K MAB C

D*

S D A *

Not Used

No Driving

L

Hearing

CDL Only

Balance

(All license

types)

K

Not Used

No Driving

Please indicate if any of the following apply to this medical review:

Non-standard review time frame_____________________________

Profile categories not marked are relevant and should be completed by another health care professional.

There are special considerations I would like to discuss with a representative of the Department or the Medical Advisory Board.

I have not examined this patient recently or completely enough to have a valid judgment.

I recommend this driver complete a driving skills test in an appropriate vehicle. (Driving skills test is not available for profile Level 8)

* Recommended Restrictions:

Speed-posted 40 mph or less Area

Daylight only

Oxygen while driving

K = for Division use only DST = Driving Skills Test MAB = Medical Advisory Board C= Commercial

_____________________________________________________________________________________________________________________________________

Date (current within 6 mos.) Printed Name of Health Care Professional and DegreeSignatureState License Number

________________________________________________________________________________________________________________________________________

Street AddressCityStateZip CodeTelephoneFax Number

Doctor’s Comments________________________________________________________________________________________________________________________________________

______________________________________________________________________________________________________________________________________

Date (current within 6 mos.) Printed Name of Health Care Professional and DegreeSignatureState License Number

________________________________________________________________________________________________________________________________________

Street Address

City

State

Zip Code

Telephone

Fax Number

Doctor’s Comments______________________________________________________________________________________________________________________

DLD 134 Rev. 8-10

Form will not be processed without complete medical information

 

For overview see reverse side

FOR USE AS AN OVERVIEW ONLY

Functional ability profiles serve to define a person’s physical, mental, or emotional health in a way that it can easily be related to issuing regular or restricted driver licenses.

This table shows, in general, the principle requirements for each level and may be used as a rough guide only. A full narrative description and table for each category are found in the

Functional Ability In Driving: Guidelines and Standards for Health Care Professionals, which is available at a Utah Driver License Division office or on-line at www.driverlicense.utah.gov

Level

 

A

 

B

 

C

 

D

 

E

 

F

 

G

 

H

 

 

I

 

 

Diabetes &

 

Cardio-

 

Pulmonary

 

Neurologic

 

Seizures &

 

Learning

 

Psychiatric

 

Alcohol &

 

Visual

 

 

Metabolic

 

vascular

 

 

 

 

 

Episodic

 

Memory

 

Emotional

 

Other Drugs

 

Acuity

 

 

Conditions

 

 

 

 

 

 

 

Conditions

 

 

 

Condition

 

 

 

 

 

1

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No history

 

No past history

 

No disease

 

No history or

 

No history or

 

No history or

 

No history or

 

No history or

 

 

 

 

 

 

 

or fully

 

or fully

 

fully

 

none in 5

 

fully

 

no symptoms

 

no problems

 

 

 

 

 

 

 

recovered

 

recovered

 

recovered

 

years w/o

 

recovered

 

for 2 years

 

within 2 years

 

AONCOMPLETEDBE

EXAMINATION"VISUAL

 

 

 

 

 

 

 

 

 

 

medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2

 

Adult, stable

 

All Class I

 

Minimal

 

Minimal

 

Seizure free 1

 

Minimal

 

Stable 1 year

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

with non-

 

rhythm, no

 

symptoms.

 

impairment,

 

year, off

 

difficulty

 

with or

 

consequences

 

 

 

 

 

insulin

 

limits, no

 

No steroids

 

able to

 

medication

 

with good

 

without

 

within past

 

 

 

 

 

stimulation,

 

symptoms on

 

 

 

control

 

 

 

adjustment

 

medication

 

year

 

 

 

 

 

diet and/or

 

ordinary

 

 

 

equipment

 

 

 

 

 

 

 

 

 

 

 

 

 

oral meds

 

activity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

 

Stable on oral

 

Class I rhythm

 

Symptoms

 

Slight

 

Seizure free 1

 

Slight

 

Stable 3

 

No

 

 

 

 

 

insulin-

 

stable, with

 

on activity,

 

impairment,

 

year, on

 

impairment

 

months with

 

consequences

 

 

 

 

 

stimulating

 

pacemaker for

 

intermittent

 

able to

 

medication

 

with good

 

or without

 

within past 6

 

 

 

 

 

agent and/or

 

6 months

 

steroids FVC

 

control

 

 

 

judgment

 

medication

 

months

 

 

 

 

 

diet

 

Symptoms with

 

& FEV>50%

 

equipment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

strenuous

 

of normal

 

 

 

 

 

 

 

 

 

 

 

SHOULDPROFILE

"CERTIFICATEOF

 

 

 

 

activity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4

 

Stable on

 

Class II rhythm,

 

Stable with

 

Moderate

 

Seizure free 6

 

Moderate

 

Stable 1

 

No

 

 

 

 

 

 

 

 

 

 

 

 

insulin for 1

 

stable for 3

 

O2 or

 

impairment

 

months on

 

impairment

 

month with

 

consequences

 

 

 

 

 

year

 

months

 

steroids,

 

of dexterity

 

medication

 

with good

 

medication

 

within past 3

 

 

 

 

 

 

 

Diastolic under

 

dyspnea on

 

 

 

 

 

judgment

 

 

 

months

 

 

 

 

 

 

120

 

exertion

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

 

Stable for 6

 

Class III

 

PO2 over 50,

 

Moderate

 

Seizure free 3

 

 

 

Minimal

 

No

 

 

 

 

 

months

 

anticipated

 

symptoms

 

impairment

 

months on

 

 

 

dyskinesia,

 

consequences

 

 

 

 

 

 

 

aggravation by

 

w/ordinary

 

and

 

medication

 

 

 

medications

 

within past 1

 

CATEGORYTHIS

FORM:SEPARATE

 

 

 

 

unlimited

 

activity, no

 

decreased

 

 

 

NOT USED

 

which

 

month

 

 

 

 

 

driving

 

cough

 

stamina

 

 

 

 

 

interfere with

 

 

 

 

 

 

 

 

 

 

 

syncope 3

 

 

 

 

 

 

 

coordination

 

 

 

 

 

 

 

 

 

 

 

months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6

 

Stable for 3

 

Class III

 

Severe

 

Moderate

 

Single

 

Moderate

 

As

 

Intermittent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

months

 

unstable

 

dyspnea no

 

impairment

 

recurrence

 

impairment,

 

recommended.

 

impairment of

 

 

 

 

 

 

 

rhythm,

 

syncope

 

expected to

 

over 2 years

 

variable

 

Driving under

 

function, not

 

 

 

 

 

 

 

uncontrolled

 

within 3

 

be temporary

 

Special

 

adjustment

 

direct

 

in driving or

 

 

 

 

 

 

 

hypertension

 

months

 

 

 

circumstances

 

or altered

 

supervision

 

working

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

competence

 

may be

 

hours, drive

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

from meds,

 

therapeutic

 

under

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

alcohol,drugs

 

 

 

supervision

 

 

 

7

 

 

 

 

 

 

 

 

 

Special Circumstances or under evaluation

 

 

 

8

 

Severe

 

Class IV

 

Severe

 

Impairment

 

Seizures not

 

Severe

 

Active

 

Chronic use

 

Level 10

 

 

 

 

 

 

 

 

 

 

 

unstable

 

arrhythmia with

 

dyspnea,

 

incompatible

 

controlled or

 

impairment

 

condition with

 

of alcohol or

 

20/200 or

 

 

insulin-

 

loss of

 

syncope

 

w/driving

 

interfering

 

and poor

 

risk

 

drugs

 

worse

 

 

dependant

 

conscious

 

within 3

 

 

 

medications,

 

adjustment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

with VF

 

 

 

 

uncontrolled

 

months

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

less than

 

 

 

 

Ht,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

60

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOb

 

NO

 

NO

 

NO

 

NO

 

NO

 

NO

 

NO

 

degrees

 

 

DRIVING

 

DRIVING

 

DRIVING

 

DRIVING

 

DRIVING

 

DRIVING

 

DRIVING

 

DRIVING

 

NO DRIV

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

J

 

K

 

L

 

Musculo-

 

Alertness &

 

Hearinga

 

skeletal or

 

Sleep

 

(CDL only) &

 

Chronic

 

Disorders

 

Balance

 

Debility

 

 

 

(All lic types)

 

No history or

 

No history or

 

No current or

 

fully recovered

 

problem for 2

 

past balance

 

1 year or more

 

years. ESS <6

 

problem

 

 

 

 

 

 

 

Minimal loss

 

Problems with

 

Mild balance

 

of function

 

good self-

 

(Meniere’s

 

 

 

management

 

disease)

 

 

 

ESS 7-9

 

 

 

 

 

 

 

 

 

Mild loss of

 

Mild/moderate

 

Problems but

 

function with

 

problems,

 

not

 

or without

 

good

 

incapacitating

 

compensatory

 

professional

 

 

 

device

 

management

 

 

 

 

 

ESS 10-12

 

 

 

 

 

 

 

 

 

Moderate loss

 

Moderate

 

Recurring

 

of function

 

problems

 

problem, not in

 

with or

 

related to time

 

past 3 months

 

without comp

 

of day

 

 

 

device

 

ESS 13-15

 

 

 

 

 

 

 

 

 

Limited joint

 

Moderate

 

Recurring

 

motion

 

problems

 

problems not in

 

 

 

related to time

 

past 1 month

 

 

 

and

 

 

 

 

 

circumstances

 

 

 

 

 

ESS 13-15

 

 

 

 

 

 

 

 

 

Impairment or

 

 

 

 

 

debility

 

 

 

 

 

requiring

 

 

 

 

 

assistance of

 

NOT USED

 

NOT USED

 

responsible

 

 

 

 

 

driver

 

 

 

 

 

Chronic unsafe

 

Severe

 

Chronic

 

 

 

 

 

 

 

conditions

 

problem, no

 

balance

 

 

 

medication or

 

problems

 

 

 

unsuccessful

 

 

 

 

 

therapy

 

 

 

NO

 

NO

 

NO

 

DRIVING

 

DRIVING

 

DRIVING

 

 

 

 

 

 

bDriving skills test is not allowed for a profile level 8

a Hearing should only be profiled for a commercial driver – No hearing requirements have been established for Regular Operator Licenses

Revised 8-10