PS31924-06 (01/16)
REQUEST FOR EXAMINATION OF DRIVE R
First Name of Driver Middle Name Last Name
Street Address City
Driver's License Number Date of Birth
Date and time of incident
DRIVER INFORMATION
INCIDENT INFORMATION
Location of incident
Was an accident involved?
YES NO
Was the driver given a citation?
YES NO
Check one or more of the following that apply and describe in the summary section below:
General physical/health problem
Diabetic loss of consciousness or voluntary control
Vision problem
Lack of physical driving skills
Violation of "ANY USE OF ALCOHOL/DRUG INVALIDATES LICENSE" restriction
(please attach report verifying alcohol/drug use)
Mental or emotional problem (including road rage, memory loss, etc.)
Loss of consciousness or voluntary control (seizures)
Lack of knowledge of traffic laws
Other
SUMMARY - Describe in detail the driving actions or conditions that brought this driver to your attention. Why do you feel this
driver should be re-examined? Please attach any pertinent reports that would be helpful to the driver evaluator.
Age alone cannot be considered good cause for re-examination.
I therefore submit this information to the Driver Evaluation Unit as good cause for re-examiniation
of this driver under Minnesota Statute 171.13.
Date
Phone Number
City
Title or Relationship to Driver
Law Enforcement Agency or Printed Name of Person Reporting
Badge Number (if applicable)
Signature of Officer or Person Reporting
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
DRIVER EVALUATION UNIT
445 MINNESOTA ST., SUITE 170
ST. PAUL, MN 55101-5170
Reports from family members concerning an individual’s ability to drive are confidential (M.S. 13.69). Driver and Vehicle Services is required to
disclose the identity of all other person(s) reporting at the driver’s request. Failure to provide the information requested below will result in no action
being taken on the report.
