Kansas Department of Revenue

Division of Vehicles

Officer Referral Form

This form is used to provide the Division of Vehicles with information for drivers that have been in an accident, a traffic stop or exhibited behavior which indicates the driver may have a medical condition that may impair driving abilities.

Driver's License #

Driver's First Name

Driver's Middle Name

Driver's Last Name

Driver's Street Address

Driver's Street Address Line 2

Driver's City

Driver's State

Driver's Zip Code

Driver's Date of Birth

Date of Incident

Description of Incident

Officer's Name

Officer's Title

Officer's Phone Number

Police Department Address

Other Contact Info

Other Comments

Enter your Email Address to receive a Driver Status update