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Employers Report Of Medical Exam Failure-Request For Reexamination Of Driver DS 524 - California
| Employers Report Of Medical Exam Failure-Request For Reexamination Of Driver Form. This is a California form and can be used in Administrative Hearings And Reexaminations Statewide . |
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A Public Service Agency EMPLOYER'S REPORT OF MEDICAL EXAM FAILURE/ EMPLOYER REQUEST FOR REEXAMINATION OF DRIVER California Vehicle Code Section 14606(b) requires employers to report commercial class A or B drivers who fail to qualify for a medical certificate on reexamination to the Department of Motor Vehicles. California Vehicle Code Section 13800 allows the Department of Motor Vehicles to investigate the qualifications of any driver when it appears necessary upon receiving information or upon a showing of its records. This form may be used to request the Department of Motor Vehicles to investigate the qualifications of any driver when a driver's condition or behavior may impair his or her ability to safely operate a motor vehicle. To have a driver's qualifications reevaluated by the department, please identify the driver by filling out the applicable driver information below and briefly describe the condition or actions of the driver which make you believe a reexamination by the department is necessary. This form may be used to report a commercial class A or B driver to the Department of Motor Vehicles when the driver fails to qualify for renewal of a medical certificate. Mail completed forms to: Department of Motor Vehicles Driver Safety Services Unit P.O. Box 942890, M/S J234 Sacramento, CA 94290-9890 Please complete the following information, if known, and attach a copy of the driver's medical evaluation or other pertinent information, if available. If you need further information, or need help in completing the form, please call the Driver Safety Services Unit at (916) 657-6452. DRIVER'S NAME BIRTH DATE LICENSE OR X NUMBER CLASS OF LICENSE STATE ISSUING LICENSE ADDRESS CITY STATE ZIP CODE TELEPHONE NUMBER ( NAME OF PHYSICIAN MEDICAL NUMBER TELEPHONE NUMBER ) DATE OF EXAM ( ADDRESS CITY STATE ) ZIP CODE EMPLOYER'S NAME TITLE COMPANY PHONE NO. ( COMPANY NAME AND ADDRESS CITY STATE ) ZIP CODE If you are requesting a driver be reexamined pursuant to Vehicle Code Section 13800, please complete the section below. Briefly describe the condition or actions of the driver that make you believe a reexamination by the department is necessary. SIGNATURE TITLE DATE California Relay Telephone Service for the deaf or hearing impaired from TDD Phones: 1-800-735-2929; from Voice Phones: 1-800-735-2922 DS 524 (REV. 2/2010) WWW American LegalNet, Inc. www.FormsWorkFlow.com
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