Available Forms
DMV provides two forms for reporting drivers under the Medically At-Risk Driver Program:
Form Name: Mandatory Impairment Referral
Form Number: 735-7230
Stock Number: 300457
Example: Sample of Completed Form
Use: Physicians and other health care providers MUST use this form to submit their reports as part of the mandatory reporting component of the program.
Form Name: Driver Evaluation Request
Form Number: 735-6066
Stock Number: 300230
Use: Family members, friends, health care providers, social service providers, law enforcement officials and others MAY use this form to report an unsafe driver as part of the voluntary reporting component of the program. They may also submit a letter on their agency/organization letterhead so long as it contains the same information.
Viewing Forms
To view forms, click on the form names above. Downloading/Printing Forms
Forms may be downloaded and printed directly from the Internet, using your browser's "Save As" and "Print" options while viewing them. For best results, be sure to print them on plain white paper. For helpful information, see DMV forms and publications. Ordering Forms
Forms may be ordered in bulk from the ODOT Storeroom. To do so, fax a request on your agency/organization letterhead directly to the storeroom at (503) 986-2801. Be sure to include the following in your request: - Form Name
- Form Number
- Stock Number
- Your contact and mailing information, if different than your letterhead
Submitting Forms
Completed forms and letters may be faxed to DMV's Driver Safety Unit at (503) 945-5329, or mailed to: DMV Driver Safety Unit
1905 Lana Ave., NE
Salem, OR 97314-4120 |