735 6066
User Manual: 6066
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Citation for: _____________________________________
735-6066 (7-17) STK # 300230
Was the driver issued a traffic citation?
Agency name: ______________________________________________
Date of Incident: _________________________________Request is a result of:
SECTION FOR LAW ENFORCEMENT AGENCY OR COURT ONLY
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.
REQUESTS BASED ON AGE, DIAGNOSIS AND/OR GENERAL HEALTH ALONE WILL NOT BE HONORED.
NAME OF PERSON TO BE RE-EVALUATED (Last, First, Middle)
STREET ADDRESS ZIP CODESTATECITY
SEX (Circle) ODL / CUSTOMER NUMBER DATE OF BIRTH
DRIVER EVALUATION REQUEST
Complete this form to request that DMV re-evaluate a driver’s ability to drive safely.
Sign this request in the signature block provided. Anonymous requests will not be honored.
Mail or fax completed request to: DMV, Driver Safety Unit, 1905 Lana Avenue NE, Salem Oregon 97314; FAX: (503) 945-5329.
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INSTRUCTIONS:
Officer's Title: ___________________________________
Agency Phone: __________________________________
Is this request submitted instead of a citation?
YOUR RELATIONSHIP TO THE DRIVER:
SIGNATUREYOUR NAME (Please Print)
YOUR MAILING ADDRESS (City, State, Zip Code) DAYTIME TELEPHONE NUMBER
X
DATE
FAX
Law Enforcement
Traffic Accident (attach report) Traffic Stop
Physician* Health Care Provider* (explain): _________________________________________
Relative Friend DMV Employee Court Other (explain): __________________________________
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.
* 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.
YES NO
YES NO
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.
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