Dmv Form Ds 699 PDF Details

In the realm of ensuring public safety and maintaining the integrity of our roads, the Department of Motor Vehicles (DMV) plays a crucial role, particularly through mechanisms like the DMV DS 699 form. This form serves as a formal request for the reevaluation of an individual's driving capabilities, emphasizing a community-centered approach to road safety. Designed for use by concerned relatives, friends, caregivers, vision specialists, and legal authorities, among others, the form allows for the confidential reporting of drivers who may pose a risk due to medical, physical, mental, or behavioral issues. The form's detailed sections require thorough information about the driver in question, including personal details and specific observations regarding their driving behavior and medical conditions that might impair their ability to drive safely. Furthermore, it outlines a structured process for submitting the request, either by mail or in person, to the nearest Driver Safety Office, with a stringent emphasis on the confidentiality of the reporting party to the highest degree possible, ensuring the process respects the privacy of all involved. The form also underscores the mandatory nature of certain fields, marked with an asterisk, ensuring that critical information is provided to facilitate a proper assessment. This comprehensive approach reflects the DMV's commitment to preventing accidents and safeguarding both the reported driver and the broader community from potential harm.

QuestionAnswer
Form NameDmv Form Ds 699
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesdmv reexamination, dmv ds, ca dmv form ds 699, ds 699 form

Form Preview Example

A Public Service Agency

INSTRUCTIONS:

REQUEST FOR DRIVER REEXAMINATION

1.Complete this form if you wish the Department of Motor Vehicles (DMV) to reevaluate a driver's ability to drive safely.

2.Sign this request in the signature block provided. You may request that your name not be revealed to the individual being reported. Confidentiality will be honored to the fullest extent possible.

3.Take your completed request to any DMV office or mail to: DMV, Driver Safety Office (see addresses on the next page for your local office.)

Note: All fields marked with an asterisk (*) are required.

NAME OF PERSON BEING REPORTED (FIRST, M.I., LAST)*

DATE OF BIRTH OR APPROXIMATE AGE*

 

TELEPHONE NUMBER

 

 

 

(

)

DRIVER LICENSE NUMBER

VEHICLE LICENSE PLATE NUMBER, IF AVAILABLE

 

 

 

 

 

 

 

STREET ADDRESS*

CITY*

STATE*

 

ZIP CODE*

DRIVERCONDITION—Check all appropriate boxes below. Please use the space below to provide specific details, if known, about the driver's medical (physical or mental) condition such as name of disease or illness, any medications taken, etc.

Medical Condition

Physical Condition

Mental/Emotional Condition Vision Condition

Weakness or Coordination Problems Difficulty Walking

Confused/Disoriented

Alcohol/Drug Use (Describe below) Blackouts, Seizures, Fainting Spells

Needs help with daily activities (i.e., cooking, dressing, bathing, balancing checkbook)

Other:

DRIVER BEHAVIOR—Check appropriate boxes for driving problems you have observed: (Use space below if needed for additional comments.)

Does not see or react to other cars, pedestrians, etc.

Drives in wrong lane

Drives on wrong side of the road

Acts violent or aggressive when driving Drives too slow, or stops, for no reason

Has trouble steering, braking, or otherwise controlling car Is confused by traffic

Gets lost or confused while driving near home

Fails to react to traffic signals, other cars, pedestrians, etc.

Makes turns from wrong lane

Turns in front of on-coming cars

Allows car to drift in and out of lane

Backs up or changes lanes without looking back or

checking mirrors

Applies brake and gas pedals at the same time

Slowreactionsthatmaybecausedbymedicationsordrugs Drives on sidewalk

Makes driving mistakes while talking to passengers

Falls asleep while driving

Other actions (Describe below)

You may use the space below to further describe the driver's condition(s) or action(s) which lead you to believe this driver should be reevaluated by DMV.

Please continue on the next page.

DS 699 (REV. 11/2018) WWW

*DS699*

Relative Friend Caregiver VisionSpecialist Court/Code Other:

Check here if you would like to have your name kept confidential. Confidentiality will be honored to the fullest extent possible. Unsigned reports will not be considered.

NAME (Please print)*

DAYTIME TELEPHONE NUMBER

 

(

)

 

 

 

MAILING ADDRESS (City, State, Zip Code)*

 

 

 

 

 

SIGNATURE*

DATE*

 

X

 

 

 

 

 

YOU MAY MAIL OR TAKE THIS COMPLETED FORM TO YOUR LOCAL DRIVER SAFETY OFFICE AT ONE OF THESE LOCATIONS:

Bakersfield

5800

District Blvd., Ste. 100-B

Sacramento

4700 Broadway, 2nd Flr.

 

Bakersfield, 93313

San Bernardino

Sacramento, 95820-1501

City of Commerce

5801

E. Slauson Ave., Ste. 250

1845 Business Center Dr., Ste 212

 

Commerce, 90040-3050

 

San Bernardino, 92408-3447

City of Orange

790 The City Dr., Ste. 420

San Diego

1455 Frazee Rd., Ste. 400

 

Orange, 92868-4941

 

San Diego, 92108-4378

Covina

1365

N. Grand Ave., Ste. 101

San Francisco

1377 Fell St., 2nd Floor

El Segundo

Covina, 91724-4048

 

San Francisco, 94117-2296

390 N. Pacific Coast Highway, Ste. 2075

San Jose

90 Great Oaks Blvd., Ste. 104

 

El Segundo, 90245-4470

 

San Jose, 95119-1314

Fresno

2510

S. East Ave., Ste. 310

Santa Rosa

2570 Corby Avenue

Oakland

Fresno, 93706-5112

 

Santa Rosa, 95407-6005

7677

Oakport St., Ste. 220

Stockton

710 N. American St.

Oxnard

Oakland, 94621-1906

Van Nuys

Stockton, 95202-1823

2051

N. Solar Dr., Ste. 125

6150 Van Nuys Blvd., Ste. 205

Redding

Oxnard, 93036-2650

 

Van Nuys, 91401-3333

2650

Churn Creek Rd., Ste. 200

 

 

 

Redding, 96002-1169

 

 

DS 699 (REV. 11/2018) WWW

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Put the asked particulars in the Does not see or react to other, Applies brake and gas pedals at, and You may use the space below to box.

ds 699 Does not see or react to other, Applies brake and gas pedals at, and You may use the space below to fields to fill

Type in the vital details as you are within the Relative, Friend, Caregiver, Vision Specialist, CourtCode, Other, Check here if you would like to, NAME Please print, MAILING ADDRESS City State Zip Code, SIGNATURE X, DAYTIME TELEPHONE NUMBER, DATE, YOU MAY MAIL OR TAKE THIS, Bakersfield, and City of Commerce part.

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