Fillable form may be submitted to the Department of (Services Australia)

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Services Australia, (previously DHS - Department of Human Services) is responsible for delivering services relating to health and welfare of Australian citizens. It processes payment of child support other services.

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Government of Western Australia
Department of Transport
M107A
Medical Assessment Certificate
Fitness to Drive
Applicant details - to be completed by applicant or Department of Transport
Prior to the renewal of your driver’s licence, you must take this form to your health professional who will conduct an assessment
of your tness to drive a motor vehicle. Read the detailed medical assessment instructions (M106A) for the applicant and health professional. This
form may be submitted to the Department of Transport (DoT) via email to driverservices@transport.wa.gov.au, via Electronic Medical Assessment (enquire
with your GP), or post to the Occupational Health Physician, C/O Department of Transport, GPO Box R1290, PERTH WA 6844. Mark as Condential.
PRIVATE STANDARD COMMERCIAL STANDARD
HEAVY MULTI DRIVING PASSENGER TRANSPORT DRIVER
TYPE OF VEHICLE MOTOR CAR MOTORCYCLE LIGHT RIGID MEDIUM RIGID HEAVY RIGID
COM BINATION COM BINATION INSTRUCTOR (T OR F EXTENSION)
C R LR MR HR HC MC DI PTD
CLASS
CURRENTLY AUTHORISED TO DRIVE:
APPLIED FOR:
REASON FOR REFERRAL
The Department of Transport has reason to believe that the following background information may be of some assistance:
Enquiries 13 11 56
DRIVER’S LICENCE / PERMIT NO: EXPIRY DATE:
APPLICATION TYPE:
APPLICANT SUFFERS FROM:
APPLICANT IS UNDER THE FOLLOWING TREATMENT/MEDICATION:
DOT#21 08.04.2020
FAMILY NAME
GIVEN NAMES DATE OF BIRTH
RESIDENTIAL ADDRESS
Indicate the authorisations you are proposing to retain. Any authorisations not indicated will be
i
surrendered. If you surrender an authorisation and wish to obtain it again in the future, you will
SI
be required to make an application, complete the required assessments and pay the associated
fees.
I consent to any reporting
health professional releasing
information to DoT and
DoT contacting any health
professional to obtain further
information which is relevant to
my tness to drive. I certify that
all information within this form
s true and correct.
GNATURE
ASSESSMENT OF FITNESS TO DRIVE (AFTD)
COMPLETED BY HEALTH PROFESSIONAL
ASSESSMENT OF FITNESS TO DRIVE (AFTD)
COMPLETED BY HEALTH PROFESSIONAL CONT.
SECTION 1
SECTION 2
SECTION 3
Clinical Findings - Provide where applicable:
• details of AFTD medical condition/s
• treatments
• history of episodes
• details of control or complication/s
• conditions of licence
• results of relevant investigations e.g. Hba1c for diabetes
DATE OF EXAMINATION
NAME OF REPORTING PROFESSIONAL
QUALIFICATION OF REPORTING PROFESSIONAL
YES NO
YES NO
SURGERY STAMP
/ /
DATE OF REPORT
/ /
DECLARATION
Were you familiar with the patient’s medical history prior to this examination?
I have attended this patient professionally since:
Blood Pressure Reading
Relevant AFTD Medical Condition/s
(Month/Year)
Uncorrected Corrected
L R B L R B
6/ 6/ 6/ 6/ 6/ 6/
Visual Acuity
Commercial vehicle standards - Heavy vehicle driver (class MR and
above), dangerous goods vehicle driver, passenger transport driver and
driving instructors must be examined at commercial vehicle standards.
OR
Private vehicle standards
SECTION 4
In my opinion the person who is the subject of this report:
a) Fit to drive - Meets the relevant medical criteria
b) Not t to drive - Does not meet the relevant medical criteria -
(Detail relevant clinical ndings at question 3)
c) Fit to drive with conditions - Is suitable to drive subject to
conditions - (Detail relevant clinical ndings at question 3)
Note: A conditional licence will not be issued unless adequate
supporting information is provided by the examining health
professional to the relevant department.
SECTION 5
Occupational Therapist assessment (may include driving
assessment).
On-road practical driving assessment by the DoT
By selecting this option you are conrming that the patient is t to
undertake an on-road practical driving assessment with a DoT driving
assessor.
Does this patient require specialist assessment for their suitability to drive?
YES NO
IF YES, SPECIFY DETAILS
SECTION 6
SECTION 7
SECTION 8
Recommended re-assessment period.
I have discussed this recommendation with patient.
I have examined the patient according to:
YEARS
EMAIL ADDRESS
SIGNATURE
I certify that I have examined the above-mentioned patient in accordance with
the relevant, current National Medical Standards (private or commercial vehicle
standards) as set out in the Austroads publication Assessing Fitness to Drive.
TELEPHONE
Additional medical condition(s) aecting safe driving attached.
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Completed 22 November 2021

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