Fillable Printable Dl Diabetic Report
Fillable Printable Dl Diabetic Report
Dl Diabetic Report
PS31077-15 (10/16)
Please carefully read the instructions before completing this form.
DRIVER COMPLETES THIS SECTION
1.
While driving, operating or in physical control of a motor vehicle, have you had an episode of loss of consciousness due to hypoglycemic
(low blood sugar) episode within the last 4 years?
Loss of consciousness means being unable to assume and retain an upright posture without support or being unable to overcome a hypoglycemic
(low blood sugar) episode symptoms without third party assistance.
2. Have you had other non-driving related episodes of loss of consciousness within the last 4 years?
I certify that the information provided above is accurate. I understand that any episode of loss of consciousness that occurs while driving,
operating or in physical control of a motor vehicle must be reported to the Minnesota Department of Public Safety, Driver and Vehicle Services.
The report must be made within 30 days of the episode. If I fail to make this report within 30 days, I understand that it will result in the loss of
my driving privileges.
PHYSICIAN MUST COMPLETE THIS SECTION
Note to Reporting Physician: Your report is advisory. Driver and Vehicle Services is responsible for determining eligibility to drive. In
accordance with the provisions of Minn. Stat. 171.131, a physician is immune from liability as a result of reporting to DVS any physical or
mental condition that significantly impairs a person's ability to safely operate a motor vehicle.
1. Diagnosis
2. Is the patient taking insulin?
3. The patient has been educated in diabetes and its management and understands the procedures that must be followed to monitor
and manage his/her diabetes and what procedures should be followed if complications arise.
4. To your knowledge, is the patient qualified, in all medical respects, to exercise reasonable and ordinary control over a motor
vehicle?
Comments:
5. A six-month or annual review is required until episode-free for four years. No recommendation results in four year review, if eligible.
The patient should be required to submit this form every:
(check one)
Printed name:
Address:
Last Name Middle Name First Name
Date of Birth (mm/dd/yy)
Yes No
Yes No
Signature
Date (mm/dd/yy)
If yes, date
(mm/dd/yy)
Yes No
Yes No
4 years 3 years 2 years 1 year 6 months
Insulin Start Date
(mm/dd/yy)
Signature of Treating Physician
Date (mm/dd/yy)
Phone: (INCLUDE AREA CODE)
- over -
Insulin-Treated Diabetes Mellitus Report
MINNESOTA DEPARTMENT OF PUBLIC SAFETY
DRIVER AND VEHICLE SERVICES
445 Minnesota Street
Saint Paul, MN 55101-5170
Phone: (651) 296-2025 Fax: (651) 282-2463
Web: dvs.dps.mn.gov
Driver's License Number
- -
-
-
X
X
(PRINT OR TYPE)
Yes No
Print Form
PS31077-15 (10/16)
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: [email protected]
• The requested information is needed to determine if your medical condition may interfere with your ability to safely
operate a motor vehicle. If your driving privileges are canceled based on the information provided by you or your
physician, you have the right to a review by the Diabetic Medical Review Board. Requests for a review must be
submitted in writing to Driver and Vehicle Services at the address listed above.
• Reporting requirements for drivers with insulin-treated diabetes are established in Minnesota Rules, chapter 7410.
Failure to provide complete and accurate information will result in the loss of your driving privileges.
• Additional waivers are required for commercial driving privileges.
MINNESOTA RULE 7410.2610 - INSULIN-TREATED DIABETES MELLITUS
Subp. 3.
Reporting diagnosis of insulin-treated diabetes or episode.
A person shall report a diagnosis of insulin-treated diabetes or an episode, in writing, to the department as follows:
A. after a diagnosis of insulin-treated diabetes:
(1) at the time of applying for a driver's license; and
(2) within 30 days after the diagnosis;
B. for a driving-related episode:
(1) within 30 days after the episode; and
(2) on a regularly scheduled physician's statement as required in subpart 3a; and
C. for a non-driving-related episode, on a regularly scheduled physician's statement as required in subpart 3a.
If a person has reason to know the requirements of items A and B, and willfully fails to report or willfully makes a material misrepresentation
to the department concerning the person's diabetic condition, the commissioner shall suspend the person's driver's license for six months. The
six-month suspension period will begin within 30 days from the date the department discovers the failure to report or misrepresentation.
Subp. 3a.
Physician's statement required.
A physician's statement, on a form prescribed by the commissioner, is required:
A. after the person:
(1) is diagnosed as having insulin-treated diabetes; or
(2) has a driving-related episode under subpart 3; and
B. every six months until the person has been episode free for a year; and then
C. annually until the person has been episode free for four years; and then
D. every four years; and additionally
E. as recommended by the physician or by the department.
The six-month, one-year, or four-year period will begin from the date the most recent physician's statement has been received and approved by
the department. During a period of cancellation or suspension under this part, the department shall not require a physician's statement until the
end of the cancellation or suspension period.
If a person fails to return a physician's statement to the department within 30 days from the date of mailing, the commissioner shall cancel the
person's driver's license until the physician's statement is submitted to the department and accepted.
The physician's statement must indicate, at least, the date of each of the person's episodes since the previous physician's statement, whether the
person is cooperating in the treatment of the condition, the person's prognosis for control of the person's diabetic condition, and whether the
person is medically qualified to exercise reasonable and ordinary control over a motor vehicle on the public roads.
Insulin-Treated Diabetes Mellitus Report
