Fillable GROUP II MEDICAL REPORT (Ashfield District Council)

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GROUP II MEDICAL REPORT (Ashfield District Council)

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APPENDIX THREE:
GROUP II MEDICAL REPORT
HACKNEY CARRIAGE & PRIVATE HIRE (DUAL) DRIVER LICENCE
NOTE FOR MEDICAL PRACTITIONERS:
In completing this Medical Certificate, Medical Practitioners are asked to have regard to
the recommendations by the Medical Commission for Accident Prevention in their book
“Medical Aspects of Fitness to Drive”.
You may find it helpful to read DVLA’s “At a Glance” booklet; downloadable from:
https://www.gov.uk/government/collections/assessing-fitness-to-drive-guide-for-
medical-professionals
Examinations must be carried out in accordance with the Group ll Medical Examination
guide.
Photographic identification must be provided by the applicant before the
examination takes place. This should be in the form of a DVLA Driver Licence
Photo-card or a Passport. Please copy the identification document, sign and date it
and attach the copy to the Medical Certificate form which will be returned to the
Licensing Team by the applicant.
Please ensure that you have obtained permission to access the applicants full
medical history before commencement of the examination.
This Certificate is not one which must be issued free of charge as part of the National
Health Service. Ashfield District Council accepts no liability to pay for it. Unless any other
arrangements have been made for the payment of the fee, the applicant is to pay.
NOTE FOR APPLICANT
The applicant may use his / her own GP for this Medical Examination or alternatively
arrangements can be made to use any other Medical Practitioner who can offer a Group II
Medical Examination and has written permission to access the applicants medical records.
Photographic identification must be presented to the GP carrying out the examination
before the medical takes place i.e. DVLA Driver Licence Photo-card or a Passport.
A Medical Report will not be accepted without a photocopy of the photographic
identification produced at the medical, signed and dated by the Medical Examiner.
Should you choose not to use your own GP then written permission to access your
medical records will be required by the Medical Practitioner undertaking the examination.
This
Group II M
edical
Certificate requires completing
and certifying
:
On first application for a Hackney Carriage & Private Hire (Dual) Driver Licence.
When reaching the ages of: 45, 50, 55, 60 and 65.
Annually when reaching the age of 65 years old, and on all other occasions
required by Council (i.e. where health issues require frequent monitoring).
Please note that an application will not be processed without the necessary certified
Group II Medical Certificate when such a Certificate is required.
1
The Department for Transport “Taxi and Private Hire Vehicle Licensing Best
Practice Guidance” recommends that the DVLA Group ll Medical Standards of
Fitness to Drive are applied to applicants for a Hackney Carriage & Private Hire
(Dual) Driver Licence.
This medical guidance is provided for anyone who considers that they may have
difficulty in meeting the required standard and who may wish to seek advice from
their GP or the DVLA before requesting a medical appointment. The list of medical
problems is not exhaustive, but covers those which may lead to refusal.
Epileptic Attack
Applicants must have been free of epileptic seizure for at least the past 10 years and
have taken anti-epileptic medication during this period
Diabetes
Applicants who are insulin dependant diabetics will not be considered fit to hold a
Hackney Carriage & Private Hire (Dual) Driver Licence unless they meet the DVLA
criteria for category C1 licences, and are able to provide a minimum of 3 months
blood glucose readings evidencing good management of this health issue.
Eye Sight
In addition to meeting the DVLA licence requirements to read a vehicle number
plate, a visual acuity of at least 6/9 in the better eye and 6/12 in the worst eye (with
or without glasses or contact lenses) together with a normal binocular field of vision
is required.
Other Medical Conditions
Applicants who have had heart problems or disturbance of cardiac rhythm or who
have persistent high blood pressure may not meet the required medical standards.
Applicants who have had recent severe head injury or major brain surgery may not
meet the required standard.
Any condition, for example, Parkinson’s Disease, Multiple Sclerosis or other ‘chronic’
neurological disorder which is likely to affect limb power and/or co-ordination may not
be accepted.
NOTE FOR APPLICANT & MEDICAL PRACTIONER
When completing this Group II Medical Report form please note as to who must
complete each Section of the form.
Section A: To be completed by the Applicant.
Section B: To be completed by the Medical Examiner.
Section C: To be completed by the Applicant.
Please remember to complete questions 1 – 13, and to sign and date the
declaration and consent, before you attend your appointment with the Medical
Practitioner. This form can be completed digitally in a PDF programme.
All 6 pages of this document must be returned to the Licensing Team when
providing your Group II Medical Report to the Council.
2
ASHFIELD DISTRICT COUNCIL
GROUP II MEDICAL CERTIFICATE:
HACKNEY CARRIAGE & PRIVATE HIRE (DUAL) DRIVER LICENCE
A. APPLICANTS DETAILS (to be completed by the applicant)
FULL NAME:
ADDRESS:
POSTCODE:
CONTACT TEL. NO.:
EMAIL ADDRESS:
DATE OF BIRTH:
HC & PH (DUAL) DRIVER LICENCE NO. (BADGE):
PLEASE PROVIDE THE DETAILS OF THE DOCTOR AND THE SURGERY WITH WHOM
YOU ARE REGISTERED.
DOCTOR’S NAME:
SURGERY ADDRESS:
POSTCODE:
PLEASE PROVIDE DETAILS OF ALL MEDICATIONS YOU ARE CURRENTLY TAKING,
AND THE HEALTH REASONS AS TO WHY SUCH MEDICATIONS ARE BEING TAKEN:
NAME OF MEDICATION HEALTH REASON FOR TAKING MEDICATION
3
B. MEDICAL EXAMINER (to be completed by the Medical Examiner)
MEDICAL EXAMINERS DETAILS (IF DIFFERENT TO THOSE LISTED IN SECTION A)
DOCTOR’S NAME:
SURGERY ADDRESS:
POSTCODE:
SURGERY TEL. NO.:
PLEASE ENTER YOUR PRACTICE STAMP IN THE SPACE PROVIDED BELOW
RECOMMENDATION OF MEDICAL EXAMINER (please tick the applicable box):
I certify that I have this day examined, in accordance with the Group II Medical guidance,
the applicant who in my professional opinion is:
Medically fit to drive taxis?
YES NO
DECLARATION OF MEDICAL EXAMINER (please tick the applicable boxes)
The applicant has provided photographic
identification, a copy of which I have signed &
dated and attached to this report.
YES NO
The applicant has provided me with written
authorisation to access their medical history to
assist me undertake this medical examination.
YES NO
Signature:
Date:
Being the Medical Examiner carrying out this Group II Medical Examination
4
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C. HEALTH SELF-DECLARATION (to be completed by the applicant)
Please select either YES or NO to each question below.
1. MEDICATION
Are you receiving any prescribed medication?
If you have answered YES, please take details of all of your medications to the Group II
Medical Examination in order that the Doctor can assess your application.
2. VISION
Do you wear spectacles or contact lenses for driving?
Do you have any other visual disorder? (such as glaucoma)
3. BRAIN AND NERVOUS SYSTEM
Have you ever suffered from or been treated for the following condition(s)?
Epilepsy
Sudden & disabling dizziness/vertigo
Stroke or TIA (Transient Ischemic Attack)
Serious head injury
Brain surgery
Chronic Neurological Disorder e.g. Parkinson’s ,Multiple Sclerosis
4. DIABETES MELLITUS (“SUGAR DIABETES”)
Do you have diabetes?
If you have answered Yes, how do you manage it?
Diet alone
Diet and tablets
Insulin injections
5. HEART AND CIRCULATION
Have you ever suffered from or been treated for the following condition(s)?
High blood pressure
Angina (chest pain when exercising)
Myocardial infarction (a heart attack)
Palpitations
Peripheral vascular disease (poor circulation)
Congenital heart disease (for example, a hole in the heart)
6. SLEEP AND BREATHING DISORDERS
Do you suffer with obstructive sleep apnoea?
`
7. MOBILITY
Do you have any problems with arthritis, neck or back pain?
8. DISABILITY
Are you registered as being disabled?
Are you disabled in any way?
5
NO
NO
NO
NO
NO
NO
NO
NO
NO
The "default" is set to "NO"
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
9. Psychiatric illnesses and dependency
Have you ever received medical attention or treatment for a psychiatric
illness? (for example anxiety, depression)
Have you ever been dependent upon alcohol or drugs?
10. Hearing
Do you have any impairment of hearing? (for example, do you wear a
hearing aid?)
11. Hospital Treatment
Have you been treated in hospital in the last five years?
If you have answered YES, please bring details of your treatment to the medical
12. DVLA
Have you ever needed to report a health concern to the DVLA?
Has the DVLA ever placed restrictions on your DVLA Driver Licence due
to problems with your health?
13. General
Have you ever suffered from or been treated for the following condition(s)?
Chest trouble (chronic bronchitis, asthma, tuberculosis)
Stomach trouble (ulcer, colitis)
Have you any other medical condition that could affect safe driving?
If you have answered Yes please provide details below:
Declaration and consent (applicant):
I confirm that the information I have provided is accurate, and that I have not
withheld any material details relating to my health.
I understand that knowingly providing false information may render me
liable to prosecution.
I authorise the doctor completing this report to provide an opinion to the
Licensing Authority of my health in relation to the standards required to hold
a Hackney Carriage & Private Hire (Dual) Driver Licence.
I authorise the doctor to retain and store this information in a manner
consistent with the Data Protection Act.
I authorise that the doctor (where this is not my GP) can have access to my
medical records to assist him/her in determining my suitability to pass a
Group II Medical Examination.
Signed: ________________________________ Dated: _____________________
6
NO
NO
NO
NO
NO
NO
NO
NO
NO
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GROUP II MEDICAL REPORT (Ashfield District Council)

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Completed 5 February 2021

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