Ensuring the safety of all drivers on the road is a critical concern for traffic authorities nationwide. With this in mind, New Jersey's Motor Vehicle Commission has implemented a procedure for reassessing the driving capabilities of individuals who may pose a risk to themselves or others while on the road. This process is facilitated through the MR-5 form, a critical document utilized by the Medical Fitness Review Unit. The form serves as a request for driver reexamination and/or medical evaluation, targeting those who might have conditions impacting their ability to safely control a vehicle, individuals involved in severe traffic incidents, habitual offenders accumulating significant points on their driving record, or those convicted of moving violations deemed severe by a judge. The form requires detailed information about the driver in question, including specifics about any incidents that led to the filing of the form, personal observations, and any relevant medical conditions or physical problems the driver may have disclosed. It is designed to be comprehensive, allowing law enforcement officers or others with grounded concerns about a driver’s fitness to operate a vehicle to formally request an evaluation. This measure not only seeks to prevent potential future accidents but also addresses the broader goal of maintaining public safety on New Jersey's roads.
| Question | Answer |
|---|---|
| Form Name | Form Mr 5 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | undersigned, undergo, New_Jersey, DOB |
MOTORVEHICLE COMMISSION
Medical Fitness Review Unit
P.O. Box 173
Trenton, New Jersey
DRIVER EXAMINATION AND/OR MEDICAL EVALUATION REQUEST
The undersigned recommends that the New Jersey licensed driver (named below) submit to a driver reexamination and/or evaluation.
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NAME:
ADDRESS:
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Reexaminationmay be required of drivers in the categories below. Please check any that apply to this driver:
1. Persons having mental OR physical disorders which may affect their ability to safely operate a motor vehicle;
2. Persons involved in a traffic accident resulting in a fatality where a violation of any of the provisions of N.J.S.A.
3. Persons who have accumulated 12 or more points as provided in N.J.A.C.
4. Persons convicted of violating any of the provisions of N.J.S.A.
I have reason to believe that this driver should submit to a reexamination and/or medical evaluation because of the information on the reverse side of this form.
Signature |
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Title
(please print or type)
Full Name
Police DepartmentICourt
Address
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Phone Number |
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Officer's Name:
Driver's Name:
Date(s) of Incident(s)
Was driver charged with any Motor Vehicle violations?
No |
Yes |
If yes, provide statute(s) code(s) and summons number(s). |
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Did an accident occur? No
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Yes |
If yes, attach copy of your accident report, including narrative or diagram. |
Upon Questioning,did the driver admit to any physical problems or medical conditions?
No |
Yes |
If yes, indicate statements |
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Have you had any contacts with the driver?
No |
Yes |
If yes, describe circumstances of contact. |
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In the space below, provide a narrative that describes why you believe that this driver should undergo a reexamination or medical evaluation. If the source of the information provided below IS someone other than yourself, provide that observer's name, full address and the telephone number where the observer can be contacted during normal working hours. If the driver contests the need for reexamination or medical review, you and/or any observers/witnesses may be subpoenaed to testify at an administrative hearing related to this matter.