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.
• You should reportonly your firsthand knowledge of the driver.
• You should complete the entire form and sign your name on the reverse side.
• After reviewing this report, the Director of Revenue may require the driver to take certain tests such as a medical, vision, or
driving test.
• All information contained in this reportshall be kept confidential,unless released by a court order.
Please provide all information available for the person being reported.
Describe in detail incidents or conditions about this driver. Give specific information such as dates, places, accident reports and
all other available information to support the need for re-examination. You should reportonly information of which you have personal
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. Age alone is not a sufficient reason for retesting.
Form 4319 (Revised 02-2014)
Name (Last, First, Middle) Social Security or DriverLicense Number
License Plate Number State of IssuanceDate of Birth (MM/DD/YYYY) Telephone Number
Address City State Zip Code
Driver Behavior
r
Traffic Violation
r
Lack of Attention
r
Dangerous Actions
r
Poor Driving Skills
r
Caused Traffic Accident or Incident
Location
Date (MM/DD/YYYY) Time
r
Lack of Knowledge of Traffic Laws
r
Obstructing Traffic
r
Other
( __ __ __ ) __ __ __ - __ __ __ __
__ __ / __ __ / __ __ __ __
___ ___ / ___ ___ / ___ ___ ___ ___
Form 4319 (Revised 02-2014)
Mail to:
DriverLicense Bureau Phone: (573) 526-2407
P.O. Box 200 Fax: (573) 522-8174
Visit www.dor.mo.gov/drivers/
for additional information.
Under penalties of perjury, I declare that the above information and any attached supplement is true, complete, and correct. Based on my
observation(s) of the above named person and information relayed to me by the individual, I reasonably and in good faith, believe that he
or she cannotsafely operate a motor vehicle. I understand that any person who intentionally files a false report shall be guilty of a Class A
Misdemeanor, and shall be liable for the damages which result.
Medical Conditions
Please select appropriate boxes if the driver being reported has any of the following conditions that would impair his or her ability
to safelyoperate a motorvehicle. Physicians, please complete Form 1528 and attach to this report.
r Cognitive Impairments or Psychiatric Disorder
(i.e., sees or hears thingsthat are not there, gets lost easily, has problems remembering wordsfor common things, confusion
in thought process or judgment) Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
r Visual Impairment
(i.e., frequently runs into objects, cannot see road signs,cannot see objects on the side without turning head). Please explain:
__________________________________________________________________________________________________
__________________________________________________________________________________________________
r Alcohol or Drug Abuse
Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
r Disorders That Impair Consciousness
(i.e., seizures, blackouts, sleep disorders) Whenwas the last loss of consciousness? __ __ / __ __ / __ __ __ __
Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
r Limited Mobility
(i.e., paralysis, problems moving freely) Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
r Other Conditions or Additional Comments
Please explain:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
Reporter’s Personal
Information and Signature
Full Name (Last, First, Middle) Relationship to Driver
Address City
State Zip Code
Telephone Number
Signature Date (MM/DD/YYYY)
( ___ ___ ___ ) ___ ___ ___ - ___ ___ ___ ___
___ ___ / ___ ___ / ___ ___ ___ ___
MM/DD/YYYY
