Health & Sight Declaration with Manager

1

Name* This field is required.

First Name

Last Name

2

Birth Date* This field is required.

Date

3

Epilepsy * This field is required.

YESNO

4

Fit(s) or blackouts* This field is required.

YESNO

5

Severe and recurrent disabling giddiness* This field is required.

YESNO

6

Diabetes controlled by insulin* This field is required.

YESNO

7

Diabetes controlled by tablets* This field is required.

YESNO

8

An implanted pacemaker or defibrillator* This field is required.

YESNO

9

Angina (heart pain) which is easily provoked by driving* This field is required.

YESNO

10

Persistent alcohol misuse or dependency* This field is required.

YESNO

11

Persistent drug misuse or dependency* This field is required.

YESNO

12

Parkinson’s disease* This field is required.

YESNO

13

Narcolepsy or sleep apnea* This field is required.

YESNO

14

Stroke, with any symptoms lasting longer than one month, recurrent “mini strokes” or TIAs* This field is required.

YESNO

15

Any type of brain surgery, severe head injury involving in-patient treatment, or brain tumor* This field is required.

YESNO

16

Any other chronic neurological condition* This field is required.

YESNO

17

A serious problem with memory or episodes of confusion* This field is required.

YESNO

18

Serious psychiatric illness or mental ill health for example diagnosis of anxiety/depression which required treatment from your GP/Specialist* This field is required.

YESNO

19

Any visual condition affecting BOTH eyes or affecting your peripheral vision (visual field) (excluding short/long sight or color blindness)* This field is required.

YESNO

20

Any persisting limb problems which requires your driving to be restricted to certain types of vehicle or those with adapted controls* This field is required.

YESNO

21

Sight in one eye only* This field is required.

YESNO

22

Visual problems affecting either eye* This field is required.

YESNO

23

Angina, other heart condition or heart operation* This field is required.

YESNO

24

I understand that I must inform the DVLA by writing to the drivers’ medical group, DVLA Swansea, SA99 1TU (the appropriate medical questionnaires can be downloaded from www.direct.gov.uk/driverhealth. Failure to do so is a criminal offense punishable by a fine of up to £1000.

AgreeDisagree

25

I confirm that the information given above is a true and accurate statement. * This field is required.I understand that if I have declared any of the conditions listed above, further medical investigations may take place. I understand I must inform you immediately if my state of health and condition alters from that stated above, any time after the date of this declaration.

26

1-. Check the driver's licence for any restrictions (#1 refers to the requirement to need corrective lenses or glasses.) If there is a restriction glasses or lenses must be worn for the test and any driving.

2- Stand the driver 20 meters from a standard car licence plate in daylight with the sun at their back. Get them to recite the licence number.

3- If multiple drivers are being tested change the number plate being read to avoid a collision

4- If the driver wears glasses or lenses for the test they must wear them to drive. In this case, the licence must confirm with an appropriate restriction. The driver must confirm and provide evidence the licence has been amended.

5- if the test is passed and the licence details are correct then the drivers SMS record should be annotated with the date.

You must be able to read (with glasses or contact lenses, if necessary) a car number plate made after 1 September 2001 from 20 metres.

27

Is there a restriction # 1 on the drivers licence?* This field is required.Check the drivers licence If there is a restriction # 1 then the driver should wear corrective lenses or glasses for the test

YESNO

28

Can the driver see correctly a normal number plate at 20 meters?* This field is required.If the driver can’t see the number plate advise them they should refer to an optician. Refuse to let them drive any company vehicle and fail the test.

YESNO

29

Did the driver wear glasses or corrective lenses for the test?* This field is required.If yes then they must wear glasses to drive. ( ensure the licence is marked by the DVLA with a restriction #1)

YESNO

30

PASS or FAIL?* This field is required.If the vision test is passed and the drivers licence is correctly identified as to the restriction status. The driver can continue to drive company vehicles.

PASSFAIL

31

Number Plate * This field is required.Please enter Numberplate

32

Driver SignatureDriver Must Sign.

33

Manager doing assessment* This field is required.Please select

34

Manager SignatureI do authorise you to operate vehicles

35