Fillable Printable Form DS-874C - Supplement to: Medical Examination of Driver Report - New York

Form DS-874C - Supplement to: Medical Examination of Driver Report - New York

SUPPLEMENT TO: Medical Examination

of Driver Report Under Article 19-A

This form is to be used ONLY as a supplement to the Medical Examination form (DS-874), and should be attached to that form

when completed. This form (DS-874C) is not required to be used, but if additional space is needed by the examining medical

staff or the driver being examined, this is the proper form to be used.

HEALTH HISTORY (additional driver and/or medical examiner comments and information)

DS-874C (6/15)

PHYSICAL EXAMINATION (additional comments)

MEDICAL EXAMINER’S CERTIFICATION & REMARKS (additional remarks)

When used, this form MUST BE ATTACHED

to the completed form DS-874, Medical Examination Report of Driver Under Article 19-A.

This form, by itself is NOT a valid Medical Report.

Continued from item on form DS-874

Driver Last Name Driver First Name M.I. Client ID # Date

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