Fillable Printable Form DS-1 - Out-of-State Drinking/Drugged Driving Program Enrollment and Status Form - New York

Form DS-1 - Out-of-State Drinking/Drugged Driving Program Enrollment and Status Form - New York

OUT-OF-STATE DRINKING/DRUGGED DRIVING PROGRAM

ENROLLMENT AND STATUS FORM

DS-1 (3/15)

PAGE 1 OF 2

Individuals convicted of an alcohol and/or drug-related offense in New York State (NYS) may substitute a qualifying out-of-state

drinking/drugged driver program for the NYS Alcohol and Drug Rehabilitation Program (DDP) in order to satisfy court-ordered

DDP requirements and/or to obtain a conditional driver license/privilege.

This document is to be completed by the qualifying program and signed by the director/coordinator, as well as the motorist, and

forwarded to the New York State Department of Motor Vehicles (NYS DMV). This form serves as an attestation that the program

meets the requirements set forth below and provides for a mechanism to track the progress of the motorist from enrollment

through the satisfaction of all requirements including treatment (if needed) and, ultimately, program completion.

Out-of-State Program Requirements:

1. The program must be approved or accepted by the state in which it is located to provide instruction to alcohol and drug

related driving offenders.

2. The program must have an educational component consisting of a minimum of 12 hours of in-person

alcohol and drug

related education. On-line programs do not meet the NYS DMV requirement.

3. The program must include a screening component using a standardized written screening instrument to evaluate whether

the individual requires further evaluation or treatment.

a. If the selected program lacks a screening component, a substance use disorder assessment/evaluation must be

completed by an approved Substance Abuse and Mental Health Services Administration (SAMHSA) provider. To

locate a provider, visit the SAMHSA website at http://findtreatment.samhsa.gov

b. Any recommended treatment must be completed before the out-of-state program provider reports a status of

completion to the NYS DMV.

Date of Birth

Telephone #

( )

Email Address

NYS License ID #

Out-of-State License ID #

Participant Name

Mailing Address

SECTION 1

Verification of Enrollment

PARTICIPANT INFORMATION (PLEASE PRINT)

Instructions: This section must be completed by an out-of-state program for offenders of alcohol or drugged driving upon

participant enrollment, and signed by both the program director/coordinator and participant. This form is for the exclusive use

of qualifying out-of-state programs, as defined above. If you are not sure whether an out-of-state program qualifies, please

contact the NYS Drinking Driver Program at (518) 473-7174.

This original form is to be retained by the out-of-state program. A signed copy of this document must be provided to the

participant, and a second copy sent to:

New York State Department of Motor Vehicles, Drinking Driver Program, 6 Empire

State Plaza, Room 336, Albany, NY, 12228. Fax (518) 486-6597.

Please note,

NYS DMV will verify all information submitted on this form with the identified course provider.

PAGE 2 OF 2

DS-1 (3/15)

Telephone #

( )

Program Start Date Anticipated Completion Date

Fax #

( )

Email address

Are participants required to have a substance use disorder

assessment/evaluation?

Contact Name

Program Name

Address

PROGRAM INFORMATION

SECTION 1

Verification of Enrollment (continued)

o Yes o No

Director/Coordinator’s Name (print)

Director/Coordinator’s Signature

I understand that the outcome of my participation in this program will be reported to the NYS DMV and failure to meet the

program’s requirements may result in the revocation of my conditional license or privilege. A false statement on this

application may be punishable as a crime under the New York State Penal Law.

Date

CERTIFICATION:

I certify under penalty of law that the participant identified above has enrolled into our state’s program for alcohol or drugged

related driving offenders. I understand the NYS Drinking/Drugged Driver Program education and screening criteria, as set

forth in this document, and attest that this program complies with all requirements. I understand that if the participant fails to

meet any of the requirements of the Drinking Driver Program, I will notify NYS DMV immediately as this may result in the

revocation of the participant’s conditional driver license/privilege.

AUTHORIZATION:

I consent and authorize communication between the out-of-state program for offenders of alcohol or drugged driving identified

above and NYS DMV of any information pertaining to my current and/or any past impaired driving/intoxicated offense(s).

Participant’s Signature Date

SECTION 2

Instructions: This section must be completed by an out-of-state program for offenders of alcohol or drugged driving upon

completion of all program requirements, including any recommended treatment noted above, and signed by both the program

director/coordinator and participant. If the participant fails to successfully complete the program, the program director or

coordinator must notify the NYS DMV immediately.

This original form is to be retained by the out-of-state program. A signed copy of this document must be provided to the

participant, and a second copy sent to:

New York State Department of Motor Vehicles, Drinking Driver Program, 6 Empire

State Plaza, Room 336, Albany, NY, 12228. Fax (518) 486-6597.

Please note,

NYS DMV will verify all information submitted on this form with the identified course provider.

o I confirm that ___________________________________________________________ has successfully completed this

program (this includes any additional treatment required based on the assessment/evaluation) on _______________.

Verification of Program Outcome

o I confirm that ___________________________________________________________ did not complete this program

for the following reason:

Date

(Client’s Name)