Medical Condition Notication
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 aect 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 notied 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
Certicate 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 aect 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 notied TMR?
No
No
Yes
Yes
You are required to give TMR a completed Medical
Certicate for Motor Vehicle Driver (form F3712).
You are required to give TMR a completed Medical
Certicate 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?
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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
notication?
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
Certicate 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.
