Transcription of Medical assessment certificate: Fitness to drive (Form M107A)
1 Government of Western AustraliaDepartment of TransportM107 AMedical assessment CertificateFitness to drive Applicant details - to be completed by applicant or Department of TransportPrior to the renewal of your driver s licence , you must take this form to your health professional who will conduct an assessment of your Fitness to drive a motor vehicle. Read the detailed Medical assessment instructions (M106A) for the applicant and health professional. This form may be submitted to the Department of Transport (DoT) via email to via Electronic Medical assessment (enquire with your GP), or post to the Occupational Health Physician, C/O Department of Transport, GPO Box R1290, PERTH WA 6844. Mark as STA NDA RDCOMMERCIAL STANDARDHEAV Y MULTI DRIVING PASSENGER TRANSPORT DRIVER TYPE OF VEHICLEMOTOR CARMOTORCYCLELIGHT RIGIDMEDIUM RIGIDHEAVY RIGIDCOMBINATIONCOMBINATIONINSTRUCTOR(T OR F EXTENSION)CRLRMRHRHCMCDIPTDCLASSCURRENTL Y AUTHORISED TO drive :APPLIED FOR:REASON FOR REFERRALThe Department of Transport has reason to believe that the following background information may be of some assistance:Enquiries 13 11 56 DRIVER S licence / PERMIT NO: EXPIRY DATE:APPLICATION TYPE:APPLICANT SUFFERS FROM:APPLICANT IS UNDER THE FOLLOWING TREATMENT/MEDICATION:DOT#21 NAMEGIVEN NAMESDATE OF BIRTHRESIDENTIAL ADDRESSI ndicate the authorisations you are proposing to retain.
2 Any authorisations not indicated will be isurrendered. If you surrender an authorisation and wish to obtain it again in the future, you will SIbe required to make an application, complete the required assessments and pay the associated consent to any reporting health professional releasing information to DoT and DoT contacting any health professional to obtain further information which is relevant to my Fitness to drive . I certify that all information within this form s true and OF Fitness TO drive (AFTD) COMPLETED BY HEALTH PROFESSIONALASSESSMENT OF Fitness TO drive (AFTD)COMPLETED BY HEALTH PROFESSIONAL 1 SECTION 2 SECTION 3 Clinical Findings - Provide where applicable: details of AFTD Medical condition/s treatments history of episodes details of control or complication/s conditions of licence results of relevant investigations Hba1c for diabetesDATE OF EXAMINATIONNAME OF REPORTING PROFESSIONALQUALIFICATION OF REPORTING PROFESSIONALYESNOYESNOSURGERY STAMP//DATE OF REPORT//DECLARATIONWere you familiar with the patient s Medical history prior to this examination?
3 I have attended this patient professionally since:Blood Pressure ReadingRelevant AFTD Medical Condition/s(Month/Year)UncorrectedCorrec tedLRBLRB6/6/6/6/6/6/Visual AcuityCommercial vehicle standards - Heavy vehicle driver (class MR and above), dangerous goods vehicle driver, passenger transport driver and driving instructors must be examined at commercial vehicle vehicle standardsSECTION 4In my opinion the person who is the subject of this report:a) Fit to drive - Meets the relevant Medical criteriab)Not fit to drive - Does not meet the relevant Medical criteria -(Detail relevant clinical findings at question 3)c) Fit to drive with conditions - Is suitable to drive subject toconditions - (Detail relevant clinical findings at question 3)Note: A conditional licence will not be issued unless adequatesupporting information is provided by the examining healthprofessional to the relevant 5 Occupational Therapist assessment (may include driving assessment ).
4 On-road practical driving assessment by the DoTBy selecting this option you are confirming that the patient is fit to undertake an on-road practical driving assessment with a DoT driving this patient require specialist assessment for their suitability to drive ?YESNOIF YES, SPECIFY DETAILSSECTION 6 SECTION 7 SECTION 8 Recommended re- assessment have discussed this recommendation with have examined the patient according to:YEARSEMAIL ADDRESSSIGNATUREI certify that I have examined the above-mentioned patient in accordance with the relevant, current National Medical Standards (private or commercial vehicle standards) as set out in the Austroads publication Assessing Fitness to Medical condition(s) affecting safe driving attached.
![FORM 9 [See Rule 18(1)] FORM O F APPLICATION FOR THE ...](/cache/preview/4/4/9/a/5/d/5/3/thumb-449a5d534d4133b59c41a1fadef3512a.jpg)
