Medical Condition Notication
Transport Operations (Road Use Management) Act 1995
Transport Operations (Marine Safety) Act 1994
Page 1 of 2 LTSR Forms Area F4355 CFD V01 Aug 2021
In this document, a reference to a medical condition means a
mental or physical incapacity.
This form is to be used by you, as a driver on Queensland
roads, to notify the Department of Transport and Main Roads
(TMR), as required by law, that you have a medical condition
that is likely to adversely aect your ability to drive safely.
This medical condition may be one of the following–
any permanent or long term medical condition
any permanent or long term increase in, or other
aggravation of a medical condition about which you have
previously notied TMR.
You are not required to notify TMR if your medical condition is
of a temporary nature.
If you are required to give TMR a completed Medical
Certicate for Motor Vehicle Driver (form 3712) with this form
and if it is not provided, your driver licence will be immediately
suspended.
1. Your driver licence details
Driver licence number
Please print clearly in dark pen (not pencil or erasable ink).
Expiry date
/ /
2. Your personal details
Family name
Given name/s
State/Territory/Country of issue
Date of birth (dd/mm/yyyy)
Residential address
Postal address (if same as residential, write ‘as above’)
/ / Male Female
Postcode
Postcode
Telephone/mobile number
Email address
Do you have a permanent or long term medical condition
that is likely to adversely aect your ability to drive a motor
vehicle safely?
Has there been a permanent or long term increase in, or
aggravation of, a medical condition about which you have
previously notied TMR?
No
No
Yes
Yes
You are required to give TMR a completed Medical
Certicate for Motor Vehicle Driver (form F3712).
You are required to give TMR a completed Medical
Certicate for Motor Vehicle Driver (form F3712).
Do you need to wear glasses/contact lenses for driving?
Would you like to get e-notices and e-reminders?
Yes
Yes
No
No
3. Your medical condition
If you answered Yes to wearing glasses/contact lenses for
driving, do you agree to your Queensland driver licence
being amended to add a S condition?
continued next column...
continued page 2...
Are you voluntarily surrendering your Queensland driver
licence because you can no longer drive due to a medical
condition?
5. Voluntary surrender
No
Yes
Have you enclosed your driver licence with this
notication?
Yes
No
What is the reason for not enclosing your
driver licence?
I have already returned my driver licence to:
Location
I have not returned my driver licence
because it has been:
Destroyed
Lost Stolen
Other give details below
If you are a Queensland licence holder, you may be eligible
for a refund of the unexpired portion of your driver licence.
Please indicate below if you would like TMR to consider your
request for a refund?
No
Yes
TMR may contact you for additional information.
4. Queensland driver licence amendment
Yes
No
If your driver licence requires amendment you
will need to complete a separate Driver Licence
Amendment (form F4358), which may delay the
reissue of your driver licence.
Do you agree to the amendment of your Queensland driver
licence for the purpose of adding/removing a class and/or
condition from your driver licence?
Do you have any other vision or eye disorders?
No
Yes You are required to give TMR a completed Medical
Certicate for Motor Vehicle Driver (form F3712).
Yes
No
A replacement driver licence will be sent to your
nominated mailing address, you should allow up to
two weeks for delivery.
You will receive a written notice proposing the
amendment of your driver licence.
Print Form
Reset Form
Note: You may give notication by–
Page 2 of 2 LTSR Forms Area F4355 CFD V01 Aug 2021
Date notied
/ /
Oce use only
Medical Condition Notication continued... page 2 of 2
Notication method–
Email Mail Fax In person
Medical certicate presented?
Other medical report attached?
If the refund is to be issued by EFTPOS/Credit Card: I conrm
that all requirements have been met to issue an electronic
refund.
No
No
Yes
Yes
Date
/ /
Authorised person’s name (please print)
Verifying operator’s username
Signed
Verifying operator’s signature
Oce stamp
Notes
Email:
Mail:
Facsimile:
In person:
mcr@tmr.qld.gov.au
Department of Transport and Main Roads
Locked Bag 2000 Red Hill
ROCKHAMPTON QLD 4701
07 4931 1624
At any departmental customer service centre or
driver licence issuing centre.
Date
/ /
I declare that the information I have provided in this form is
true and I understand–
that action may be taken to amend, suspend, or cancel my
driver licence if it is proven the driver licence was obtained
on the basis of information I knew was false or misleading
and that I may be prosecuted as a result.
7. Your declaration
Signed
Privacy statement
TMR provides this form under the Transport Operations (Road Use Management)
Act and the Transport Operations (Marine Safety) Act for you to notify TMR about
your medical tness to continue to hold a driver licence and/or marine licence.
The information given in this form may be used by TMR to decide whether you
are medically t to continue to hold a driver licence and/or marine licence.
This information is accessible by authorised departmental persons and may
be disclosed to the Queensland Police Service and interstate driver licensing
authorities. TMR will not disclose your personal details to any other third parties
without your consent unless authorised or required by law.
6. Do you have a Queensland marine licence?
No
Yes
Do you want to surrender your marine licence?
Yes
No
A marine licence indicator card will be
sent to you.
click to sign
signature
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