Fillable Printable Driving Test Report Form - Missouri
Fillable Printable Driving Test Report Form - Missouri
Driving Test Report Form - Missouri
Driver’s Personal
Information
Missouri Department of Revenue
Driver Condition Report
Form
4319
Detail Incidents and Conditions
Please complete the Driver Condition Report if you have personal knowledge about a driver you believe is no longer able to safely
operate a motor vehicle.
•Youshouldreportonlyyourfirsthandknowledgeofthedriver.
•Youshouldcompletetheentireformandsignyournameonthereverseside.
•Afterreviewingthisreport,theDirectorofRevenuemayrequirethedrivertotakecertaintestssuchasamedical,vision,or
driving test.
•Allinformationcontainedinthisreportshallbekeptconfidential,unlessreleasedbyacourtorder.
Please provide all information available for the person being reported.
Describeindetail incidentsorconditionsaboutthisdriver.Givespecificinformationsuchasdates,places,accidentreportsand
allotheravailableinformationtosupporttheneedforre-examination.Youshouldreportonlyinformationofwhichyouhavepersonal
knowledge or physical evidence. Do not report what you have been told or heard.
Please select appropriate boxes based on personal knowledge of incident, if applicable. Please give a detailed description of
incident.Agealoneisnotasufficientreasonforretesting.
Form 4319 (Revised 02-2014)
Name(Last,First,Middle)SocialSecurityorDriverLicenseNumber
LicensePlateNumberStateofIssuanceDateofBirth(MM/DD/YYYY)TelephoneNumber
AddressCityStateZipCode
Driver Behavior
r
TrafficViolation
r
LackofAttention
r
DangerousActions
r
PoorDrivingSkills
r
CausedTrafficAccidentorIncident
Location
Date(MM/DD/YYYY)Time
r
LackofKnowledgeofTrafficLaws
r
Obstructing Traffic
r
Other
( __ __ __ ) __ __ __ - __ __ __ __
____/____/________
______/______/____________
Form 4319 (Revised 02-2014)
Mail to:
DriverLicenseBureauPhone: (573) 526-2407
P.O.Box200Fax: (573) 522-8174
JeffersonCity,MO65105-0200 E-mail: dlbm[email protected]
Visitwww.dor.mo.gov/drivers/
for additional information.
Under penalties of perjury, I declare that theabove information and any attached supplement is true, complete, and correct. Based on my
observation(s) of theabove namedperson andinformationrelayedto me by the individual, Ireasonably and in good faith, believe thathe
orshecannotsafelyoperateamotorvehicle.IunderstandthatanypersonwhointentionallyfilesafalsereportshallbeguiltyofaClassA
Misdemeanor,andshallbeliableforthedamageswhichresult.
Medical Conditions
Please select appropriate boxes if the driver being reported has any of the following conditions that would impair his or her ability
tosafelyoperateamotorvehicle.Physicians,pleasecompleteForm1528andattachtothisreport.
rCognitiveImpairmentsorPsychiatricDisorder
(i.e.,seesorhearsthingsthatarenotthere,getslosteasily,hasproblemsrememberingwordsforcommonthings,confusion
in thought process or judgment) Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
rVisualImpairment
(i.e.,frequentlyrunsintoobjects,cannotseeroadsigns,cannotseeobjectsonthesidewithoutturninghead).Pleaseexplain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
rAlcoholorDrugAbuse
Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
rDisordersThatImpairConsciousness
(i.e.,seizures,blackouts,sleepdisorders)Whenwasthelastlossofconsciousness?____/____/________
Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
rLimited Mobility
(i.e.,paralysis,problemsmovingfreely)Pleaseexplain:
______________________________________________________________________________________________
______________________________________________________________________________________________
rOtherConditionsorAdditionalComments
Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Reporter’s Personal
Information and Signature
FullName(Last,First,Middle)RelationshiptoDriver
AddressCity
StateZipCode
TelephoneNumber
SignatureDate(MM/DD/YYYY)
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
______/______/____________
MM/DD/YYYY
