735 6066

User Manual: 6066

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DRIVER EVALUATION REQUEST
DMV may require re-evaluation only when there is reason to believe that a driver may no longer be qualified to hold a license.
The individual may be required to take vision, knowledge or driving tests or obtain a medical clearance.
INSTRUCTIONS:
1. Complete this form to request that DMV re-evaluate a driver’s ability to drive safely.
2. Sign this request in the signature block provided. Anonymous requests will not be honored.
3. Mail or fax completed request to: DMV, Driver Safety Unit, 1905 Lana Avenue NE, Salem Oregon 97314; FAX: (503) 945-5329.
NAME OF PERSON TO BE RE-EVALUATED (Last, First, Middle)

SEX (Circle)

ODL / CUSTOMER NUMBER

DATE OF BIRTH

M F X
STREET ADDRESS

CITY

STATE

ZIP CODE

DRIVER BEHAVIOR – Check appropriate boxes for driving problems you have observed:
Does not see or react to other cars, pedestrians, etc.
Drives in wrong lane or on wrong side of road
Allows car to drift in and out of lane
Drives on sidewalk
Makes turns from wrong lane
Turns in front of on-coming cars
Acts violently or aggressively when driving
Drives too slowly, or stops, for no reason
Has trouble steering, braking, or otherwise controlling car

Applies brake and gas pedals at the same time
Is confused by traffic
Gets lost or confused while driving near home
Backs up or changes lanes without looking back or checking mirrors
Fails to react to traffic signals, other cars, pedestrians, etc.
Has slow reaction times (caused by medications, drugs or condition)
Makes driving mistakes while talking to passengers
Falls asleep while driving
Other actions (describe below)

Please use the space below and the back of this form to provide specific information such as events, dates and places which cause
you to question the individual’s ability to drive safely. If you believe the person has a medical condition/impairment that impacts safe
driving, please provide information about its impact on their ability to safely operate a motor vehicle. Attach any supporting documentation.



REQUESTS BASED ON AGE, DIAGNOSIS AND/OR GENERAL HEALTH ALONE WILL NOT BE HONORED.



Check here if you want your name kept confidential. DMV may not be able to keep this request confidential if the
driver requests a hearing or files a lawsuit against DMV.
YOUR RELATIONSHIP TO THE DRIVER:

Law Enforcement
Relative

Physician*

Friend

Health Care Provider* (explain): _________________________________________

DMV Employee

Court

Other (explain): __________________________________

* Medical providers who are required to report patients under the mandatory reporting program must use DMV Form 735-7230. Please
refer to www.OregonDMV.com for more information.
YOUR NAME (Please Print)

SIGNATURE

X

YOUR MAILING ADDRESS (City, State, Zip Code)

DATE

DAYTIME TELEPHONE NUMBER

FAX

SECTION FOR LAW ENFORCEMENT AGENCY OR COURT ONLY
Request is a result of:

Traffic Accident (attach report)

Traffic Stop

Date of Incident: _________________________________

Was the driver issued a traffic citation?

YES

NO

Citation for: _____________________________________

Is this request submitted instead of a citation?

YES

NO

Officer's Title: ___________________________________

Agency name: ______________________________________________
735-6066 (7-17)

Agency Phone: __________________________________
STK # 300230
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