Form DL 145 Virginia

Traumatic Brain Injury Designation Application

Use this form to apply for a traumatic brain injury designation on your driver's license.

This document is a traumatic brain injury designation application form for individuals with disabilities. The applicant provides personal information, including full legal name, DMV number or social security number, current residence address, city, state, zip code, birth date, and injury information such as the date of injury. The form requires a medical assessment by a licensed physician, nurse practitioner, or physician's assistant to determine if the patient's driving ability is impaired due to visual field cuts, residual weakness, seizure treatment required, slurred speech, altered gait, and other impairments. The assessment determines if the patient can safely operate a motor vehicle or motorcycle, needs adaptive devices or equipment, experiences side effects of medications, and is compliant with treatment. The physician also recommends any additional restrictions and medications.