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Hospital ER physician's impaired driver report
This document is a Hospital Physician's Impaired Driver Report from the Connecticut Department of Motor Vehicles. The report allows any physician to submit, in writing, the name, age, address, date of birth, and diagnosis of patients who have chronic health problems significantly impacting their ability to safely operate a motor vehicle or experiencing recurrent periods of unconsciousness uncontrolled by medical treatment. The reports are for informational purposes only, helping the commissioner enforce state motor vehicle laws in determining eligibility to operate a motor vehicle. Required fields include patient's name, address, date of examination, type and other impairment or medical condition, physician's comments and certification, physician's name, signature, hospital name, telephone number, report date, physician's specialty, license number, state of issue, CDL/PS status, and driver's license number.
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