INSTRUCTIONS
• Mail the completed form to:
Driver and Vehicle Services, Driver Evaluation Unit, 445 Minnesota Street, St. Paul, Minnesota 55101-5170
Or fax to: (651) 282-2463
• If you have questions or need additional information:
please contact DVS at (651) 296-2025, (651) 282-6555 (TTY) or email: dvs.driverslicense@state.mn.us
• This form is used to determine your eligibility for Minnesota driving privileges. Your verified statement on this form, plus a
report from your doctor, is collected by the authority of Minnesota Statute 171.13 and will be used only by authorized
Driver and Vehicle Services division personnel.
• Your doctor will need to express an opinion regarding your present physical condition as it pertains to your safe operation
of a motor vehicle upon the streets and highways.
• Loss of consciousness or voluntary control means the inability to assume and retain upright posture without support, or
the inability to respond rationally to external stimuli.
• Failure to provide and return the requested data in 30 days will result in the denial of your license request and
cancelation of your driving privileges.
• Additional waivers are required for commercial driving privileges.
MINNESOTA RULE 7410.2500 - LOSS OF CONSCIOUSNESS OR VOLUNTARY CONTROL
Subp. 2.
Reports required.
A person shall report an episode of loss of consciousness or voluntary control, in writing, to the department:
A. at the time of applying for a driver's license, if an applicant has experienced an episode; or
B. within 30 days after the episode, if a driver experiences an episode.
PS31015-12 (02/16)
Loss of Consciousness or Voluntary Control Report
Each report must specify the date of the episode and must be accompanied by a physician's statement in a form prescribed by the
commissioner.
A. When a driver or applicant submits a physician's statement indicating that loss of consciousness or voluntary control resulted
from a change or removal of medication on physician's orders and the physician does not recommend cancellation or denial of the
person's driving privileges, the commissioner shall require a physician's statement every six months for a year, or at shorter
intervals as recommended by the reporting physician.
B. When a driver submits a physician's statement indicating that the episode of loss of consciousness or voluntary control was the
first episode experienced by the driver and the physician does not recommend cancellation or denial of the person's driving
privileges, the commissioner shall require a physician's statement every six months for a year, or at shorter intervals as
recommended by the reporting physician.
C. When the driver fulfills the requirements of subpart 3, item C, the commissioner shall require a physician's statement every six
months for a year, or at shorter intervals as recommended by the reporting physician.
D. When the commissioner has good cause to believe that the driver's condition is not controlled, the commissioner shall require a
physician's statement every six months, or at shorter intervals as recommended by the reporting physician.
E. If a driver has been free from episodes of loss of consciousness or voluntary control for four years, the commissioner shall
require a physician's statement every four years, unless the physician recommends more frequent reports.
Except as otherwise provided in items A to E, a driver who has experienced a loss of consciousness or voluntary control shall submit an
annual physician's statement on a form prescribed by the commissioner, regarding the driver's medical history, present situation, and the
prognosis with respect to the driver's ability to operate a motor vehicle with safety to the driver and others.
Review of driver's condition.
Subp. 5.
