This form may be used to request an evaluation of a Kansas driver when a medical, mental health and/or vision condition(s) is indicated/ suspected. You must complete all fields and choose which issues you believe may affect the driver’s ability to safely operate a motor vehicle. The information you provide will be kept confidential. Upon receipt of this evaluation request, the driver in question will receive medical and vision forms, to have completed by their providers that are familiar with their condition(s), from exams which have occurred within the last ninety (90) days. If this office receives approval from all providers, the driver will be required to take and pass a driving test at their local full service exam station for continuation of Kansas driving privileges.

I am concerned that this driver has one or more of the following conditions that may affect their ability to safely operate a motor vehicle:

Driver’s behavior/issue(s) I observed. (Please check those that apply).

Knowledge of this driver is based on observation as a: (Please check and complete additional information)