Driver Licence Medical

1 10,003 (02/2021). Driver Licence Medical This Driver Licence Medical form is applicable for Licence classes C, R and LR. Any Licence class above LR requires a Commercial Drivers Medical Assessment to be submitted. Medical forms can be obtained by visiting or calling Access Canberra on 13 22 81. If the Driver Licence Medical is submitted incomplete it cannot be accepted by the Road Transport Authority. Personal details New Licence application Existing Licence application Surname Given name Other names Date of birth Licence number Contact number Residential address Email address Visual Acuity Are corrective lenses required for driving?* Yes No *If corrective lenses are required visual acuity must be recorded with corrective lenses on. Visual Acuity - please specify Both 6/ Right 6/ Left 6/.

2 Does the patient have any visual problems? ( Glaucoma, macular degeneration) Yes No If yes, please specify below: Review period Medical examination - to be completed by Medical practitioner The examination must be conducted in accordance with the National Medical Standards described in Assessing Fitness to Drive'. This publication is available from All minimum mandatory review periods are advised within this publication. How long have you treated the patient / how long has the patient attended this Medical practice? Does the patient have any of the following conditions? Minimum Other review Please tick all boxes that apply. A tick indicates a positive response. mandatory review period as specified period by GP / Specialist Cognitive impairment 1 year Please specify Diabetes Insulin dependent 2 years Tablets 5 years Dietary None Epilepsy / Blackout 1 year Date of last episode / /.

3 Dementia Advanced Dementia 6 months Moderate Dementia 1 year Early Dementia 1 year Sleep disorder 1 year Other (psychiatric, musculoskeletal, neurological, heart disease or cardio) Review period: Please specify Medications Is the person on any medication that would adversely affect their ability to drive? No Yes Type/s: Road Transport Authority | PO Box 582 Dickson ACT 2602 | Phone: 13 22 81 Page 1 of 2. Medical opinion - to be completed by Medical practitioner I certify that I have examined the afore mentioned person in accordance with the National Medical Standards as set out in Assessing Fitness to Drive'. In my opinion the person subject of this report : Meets the relevant Medical criteria for an unconditional Licence . Does not meet the Medical criteria to hold any class of Licence .

4 Meets the Medical criteria for a conditional Licence with the following conditions / restrictions. Requires a specialist report . Specialist type: Is the person fit to drive pending the specialist report ? Yes No Requires an assessment from the Fitness to Drive Medical Unit, practical driving assessment or an occupational therapist assessment. Should the person continue to drive prior to the Fitness to Drive Medical Unit assessment? Yes No Is the person fit to undertake the practical driving assessment? Yes No No further Medical assessments are required. If no further Medical assessments are required please indicate reasons below: Medical practitioner details Full name of person Name of examining doctor (please print or stamp) Signature Date of examination Medical practice Contact number Email address Fax number Privacy Statement: The personal information on this form is being collected by Access Canberra (part of the Chief Minister, Treasury and Economic Development Directorate) for Driver licensing purposes as authorised by the Road Transport ( Driver Licensing) Act 1999.

5 The information may be used for the administration of Driver licensing and vehicle registration legislation and enforcement. Access Canberra will include your information in its one client record so that it can be used in respect of any other dealings that you might have with Access Canberra. Information about your identity, which forms part of your one client record, will also be used for administrative purposes, including to confirm that we are dealing with the correct individual. Your personal information may be disclosed to other ACT Government Directorates, Commonwealth, State and other Territory government agencies, transport authorities, law enforcement and court agencies, authorised by law; the Motor Accident Injuries Commission; authorised printing and mailing service providers; Austroads Ltd; the National Heavy Vehicle Regulator; the National Capital Authority and individuals, their agents or insurers following a report provided to the police of a motor vehicle accident.

6 Personal information and health information related to the assessment of your compliance with the required Medical standards may also be disclosed to Medical professionals and driving assessors when required to assess your ability to drive safely. Access Canberra is authorised to retain a digital copy of your photograph and signature under Part 4 of the Road Transport ( Driver Licensing) Act 1999. Retained images may be used to assist in addressing identity fraud and disclosed to law enforcement and court agencies, interstate road authorities, or when authorised by law. If you choose not to provide the personal information requested on this form, we may not be able to process your request. Personal informa- tion for this application is not normally disclosed to overseas recipients unless required by law.

7 Personal information provided is used or disclosed for the purpose for which it has been provided. Personal information is held and managed in accordance with the Information Privacy ACT 2014, and in the case of personal health information, the Health Records (Privacy and Access Act) 1997. Page 2 of 3. Information for Licence Applicants and Licence Holders The completed Driver Licence Medical must be presented to Road Transport Authority prior to the due date (please allow sufficient time for any Medical examinations / assessments etc.) in order to obtain an original Licence or avoid suspension of your current Licence . Please submit your completed Driver Licence Medical by email to by mail to Box 582 Dickson ACT 2602, or by fax to (02) 6207 7120. If applying for a new Licence , this can be submitted in the Access Canberra Service Centre at the same time as your Licence application.

8 The Driver Licence Medical is valid for six months from the date of examination. The Road Transport Authority does not acknowledge the return of Medical assessment reports. If there is a problem with the report or the report is not received by the due date, you will be contacted. Medical examination requirements for holders of an ACT Driver Licence Applicants in the following categories are required to undergo a Medical examination prior to the issue of a Licence and thereafter as outlined below. People 75 years of age or over are required to be examined annually by their own doctor. People with diabetes are required to be examined by their own doctor as follows: Insulin dependent: Medical every 2 years Tablets: Medical every 5 years Diet: No Medical required People with epilepsy are required to be examined annually by their own doctor.

9 However, should they be seizure free and off medication for an extensive period, their doctor may recommend them as safe to have the condition removed from their Licence record. If a person with epilepsy has a seizure at any time, they should see their doctor prior to recommencing driving. People with heart condition / disease before commencing or recommencing driving after the onset of a condition, are required to take this Medical form to their general practitioner who will determine whether they can assess their fitness to drive, or whether they will need to be assessed by a specialist, a cardiologist. Thereafter an annual examination with their general practitioner is required unless otherwise specified on the Medical . People with other disabilities ( paralysis, amputees, etc.)

10 Are required to undergo a Medical examination with their general practitioner before recommencing driving after the onset of a condition. Should you wish to apply for an internal review of the Road Transport Authority's decision to request a Medical , applications for review should be addressed to: The Manager, Road Transport Authority, PO Box 582 Dickson, ACT 2602. An application for internal review must be made within 28 days of receiving this request. If you are dissatisfied with the outcome of the internal review, you have the right to apply to the ACT Civil and Administrative Tribunal (ACAT) to review the decision of the internal review. An application to the ACAT can only be made following an internal review. Applications to the ACAT must be made within 28 days of the date of the decision of the internal review.