Dld 134 Form – Fill Out and Use This PDF

	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

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

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Street AddressCityStateZip CodeSocial Security Number / ITIN

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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: _______________________________________________________

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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.

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

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Street AddressCityStateZip CodeTelephoneFax Number

Doctor’s Comments________________________________________________________________________________________________________________________________________

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

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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

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