Form NHTSA Form 1228 NHTSA Form 1228 DRIVER MEDICAL REVIEW PRACTICES

OMB No. 2127-XXXX
Expiration Date: xx/xx/xxxx

Instructions for Survey Completion

In the following pages, you will find a 63-question survey. Please save this document to your computer, where you’ll be able to find it later (in Microsoft Word 2010, select “file,” and then “save as”).

As you will see, the majority of the questions have check box responses, while some questions ask for a descriptive response. Some of the questions with check box responses direct you to “check all that apply,” while others are simple “Yes” or “No” check boxes. Just click in the box to place an “X” in it, and if you change your mind, click in the box again, and the “X” will disappear. Some questions have a direction to “click here to enter text.” Do just that, and the box will expand as you type your responses.

Each time you work on the document, make sure you save your changes before you close it (select “File” and then “Save”).

Question 63 asks you to provide clarification for any of the questions that were difficult to answer based on the response options provided. As you go through the survey questions, if you find that you need more space or different options for answering questions, please list the question number, and type your clarifications in the space provided in question 63.

Paperwork Reduction Act Burden Statement

A federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number.  The OMB Control Number for this information collection is 2127-XXXX..  Public reporting for this collection of information is estimated to be approximately 2.5 hours per response, including the time for reviewing instructions, completing and reviewing the collection of information.  All responses to this collection of information are voluntary.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, National Highway Traffic Safety Administration, 1200 New Jersey Avenue, SE Washington, DC, 20590, Washington, D.C. 20590.

DRIVER MEDICAL REVIEW PRACTICES

For passenger vehicle drivers only (cars, vans, pick-up trucks)

Please contact Kathy Lococo (215-538-3820, ext. 104) with any concerns or for assistance with any questions that need clarification.

INFORMATION ABOUT STATE AND SURVEY RESPONDENT

1. State: Click here to enter text.

2. Survey Respondent Name: Click here to enter text.

3. Survey Respondent Title or Position: Click here to enter text.

4. Phone Number: Click here to enter text.

5. Email: Click here to enter text.

MEDICAL ADVISORY BOARD (MAB) COMPOSITION AND ROLE

6. Does your State currently have a Medical Review or Medical Advisory Board (MAB) or formal liaison with another office, department, or division that functions as a MAB (e.g., a State Health Office)?

☐Yes ☐No If “No,” but there was a Board in the past that contributed to policies, procedures, and guidelines, please describe that Board and its roles and responsibilities below.

Click here to enter text.

Then, all “No” responses skip to Question #22

7. In which of the following activities does the Board participate? (Please check all that apply to the current MAB)

☐Advise the driver Licensing Agency on medical criteria and/or vision standards for licensing

☐Review and advise on individual cases referred by Licensing Agency case review staff (Check all that apply)

☐Paper/electronic document reviews

☐In-person or videoconferencing interviews

☐In-person screening or assessment of fitness to drive (paper-and-pencil tests or computerized battery of visual, mental, and/or physical abilities)

☐Review and advise on individual cases for drivers appealing the Licensing Agency’s license action (Check all that apply)

☐Paper/electronic document reviews

☐In-person or videoconferencing interviews

☐In-person screening or assessment of fitness to drive (paper-and-pencil tests or computerized battery of visual, mental, and/or physical abilities)

☐Assist Licensing Agency in developing medical forms for completion by drivers’ treating physicians

☐Assist Licensing Agency in developing forms used by law enforcement, the public, physicians, etc. to report drivers to the licensing agency with suspected medical or functional impairments

☐Assist in development of educational materials on driver impairment for the general public

☐Participate in the recommendation, development, and/or delivery of training courses or materials for driver license examiners in medical/functional aspects of fitness to drive

☐Participate in the recommendation, development, and/or delivery of training courses or materials for law enforcement, physicians, and/or the courts in medical/functional aspects of fitness to drive and how to report drivers to the licensing agency with suspected medical or functional impairments

☐Apprise Licensing Agency of new research on medical/functional fitness to drive

☐Advise on medical review procedures

☐Other (explain): Click here to enter text.

8. How many Board positions are there? Click here to enter text.

8a. How many of these positions are presently filled? Click here to enter text.

9. Is the Board divided into committees or subcommittees? ☐ Yes ☐ No (if “No” skip to Question #10)

9a. If “Yes,” please explain (e.g., how many committees and how many members on each?)

Click here to enter text.

10. What medical specialties are represented by the Board Members? (Check all that apply)

☐ Cardiologists ☐ Drug/Alcohol Rehab ☐ Emergency Medicine ☐ Endocrinologists ☐ Family Practice ☐ General Surgery ☐ Geriatrics/Gerontology

☐ Internal Medicine ☐ Neurologists ☐ Nurses ☐ Occupational Medicine ☐ Ophthalmologists ☐ Optometrists ☐ Orthopaedics

☐ Pharmacologists ☐ Physiatrists ☐ Psychiatrists ☐ Psychologists ☐ Pulmonologists/Pulmonary Specialists ☐ Radiologists

10a. List any other medical specialties represented by the Board that are not listed above:

Click here to enter text.

10b. If there are other members of the Board who are not physicians, please describe them here:

Click here to enter text.

11. What is the employment of the Board physicians? (Check all that apply)

☐Full-time employees of the Licensing Agency

☐Part-time employees of the Licensing Agency

☐Paid consultants to the Licensing Agency

☐Volunteer consultants to the Licensing Agency

12. If Board physicians are NOT employed by the Licensing Agency (i.e., if they are consultants), who are they employed by? (Check all that apply)

☐Private practice

☐Hospital/clinic

☐Department of Health

☐Other Government agency (list, if known) Click here to enter text.

☐Other (list, if known) Click here to enter text.

☐Retired

13. If Board members are paid consultants to the Licensing Agency, describe compensation: Click here to enter text.

MEDICAL ADVISORY BOARD (MAB) CASE REVIEW PROCESS

(Note: if MAB does not review individual cases referred by Licensing Agency medical case review staff, skip to Question #18)

14. When the MAB reviews individual cases referred by the Licensing Agency medical case review staff, how are fitness to drive recommendations determined (or recommendations for further testing)? (Check only 1 response):

☐ Review by one MAB physician

☐ Consensus of a group of MAB physicians

☐ Could be either 1 MAB physician but sometimes it is by consensus of a group of MAB physicians

☐ Other (Describe): Click here to enter text.

15. How many individual cases referred by Licensing Agency case review staff did the MAB review in 2012?

Click here to enter text.

16. What types of cases are generally referred to the MAB for review? Click here to enter text.

17. What types of dispositions may the Board recommend? (Check all that apply)

☐Suspension/revocation

☐Restrictions (e.g., daytime only, geographic, radius of home, special adaptive equipment)

☐Further Licensing Agency Testing (road, knowledge, vision)

☐Further assessment by a Driver Rehabilitation Specialist

☐Periodic reexaminations or medical statements

☐Other (Explain): Click here to enter text.

18. If the MAB reviews cases appealing the Agency’s licensing decision, how many appeal cases did the MAB review in 2012? Click here to enter text.

19. Are Board members immune from legal (tort) action? ☐ Yes ☐ No

20. Are records and deliberations of the Board confidential?

☐ Yes, without exception

☐ Yes, with the following exceptions (Check all that apply):

☐ When requested for judicial action

☐ Upon driver request

☐ Other (describe): Click here to enter text.

☐ No

21. Are Board members’ identities public or do they remain anonymous? ☐ Public ☐ Anonymous

LICENSING AGENCY CASE REVIEW STAFF

22. Which best describes the individuals within the Licensing Agency who perform case review of drivers referred for medical review or reexamination? (NOTE: this is individuals other than any MAB your State may have).

(Check only 1 response)

☐ The Licensing Agency has an internal medical review unit staffed with individuals whose duties relate only to medical review activities

☐ The Licensing Agency has an internal medical review unit staffed with individuals who have other duties in addition to medical review activities

☐ The Licensing Agency has an internal medical review unit staffed both with individuals whose duties relate only to medical review activities as well as individuals who have other duties in addition to medical review

☐ The Licensing Agency does not have an internal medical review unit; all staff who perform case review of drivers undergoing medical review have other duties in addition to their medical review activities.

☐ Other (describe) Click here to enter text.

23. Are there any medical professionals (physicians or nurses) on the Licensing Agency case review staff? (NOTE, again, this is separate from any MAB your State may have).

☐ Yes

☐ No

24. What is the composition of the Licensing Agency staff who provide case review of drivers referred for medical review or reexamination?

Check all that apply, and enter the number of individuals in each category, where applicable. If physicians, please also list their medical specialties. (NOTE: this is separate from any MAB you may have).

☐ Full-time staff physicians (list medical specialties): Click here to enter text.

☐ Part-time staff physicians (list medical specialties): Click here to enter text.

☐ Full-time physician consultants/contractors (list medical specialties): Click here to enter text.

☐ Part-time physician consultants/contractors (list medical specialties): Click here to enter text.

☐ Full-time staff nurses: Click here to enter text.

☐ Part-time staff nurses: Click here to enter text.

☐ Full-time nurse consultants/contractors: Click here to enter text.

☐ Pull-time nurse consultants/contractors: Click here to enter text.

☐ Non-medical, administrative staff (e.g., customer service reps or technicians and their supervisors) whose duties relate only to medical review activities: Click here to enter text.

☐ Non-medical, administrative staff (e.g., customer service reps or technicians and their supervisors) with other duties in addition to medical review activities: Click here to enter text.

☐ Hearing officers: Click here to enter text.

☐ Driver improvement counselors: Click here to enter text.

☐ Driver license examiners: Click here to enter text.

☐ Other (describe and enter number): Click here to enter text.

☐ Other (describe and enter number): Click here to enter text.

☐ Other (describe and enter number): Click here to enter text.

LICENSING AGENCY MEDICAL REVIEW/REEXAMINATION PROCEDURES

25. What are the circumstances under which a driver may be required to undergo medical review/reexamination (examination by treating physician, and/or DMV testing)? (Check all that apply).

☐ Crash with fatality

☐ Accumulation of points (list how many and time period): Click here to enter text.

☐ Accumulation of crashes (list how many and time period): Click here to enter text.

☐ Crash report indicates driver may have a medical condition that contributed to the crash (law enforcement at a crash scene checked a box on the crash report)

☐ Upon reaching a certain age (list the age): Click here to enter text.

☐ Upon referral to the Licensing Agency by police

☐ Upon referral to the Licensing Agency by courts

☐ Upon referral to the Licensing Agency by physician

☐ Upon referral to the Licensing Agency by occupational therapist

☐ Upon referral to the Licensing Agency by family/friends/other citizens

☐ Upon self-report of a medical condition on license application

☐ Licensing Agency counter personnel or Driver License Examiner observes signs of functional impairment during renewal process

☐ Expiration of license (list number of days): Click here to enter text.

☐ Upon application for handicapped parking privileges

☐ Upon referral from an Agency for the Blind or Visually Impaired (when a driver requests such services)

☐ Other (describe) Click here to enter text.

26. In 2012, how many drivers were referred to the Licensing Agency for Medical Review or re-evaluation of fitness to drive? (These are initial referrals/letters of concern by law enforcement, physicians, family, friends, other concerned citizens, DMV counter personnel who observe signs of impairment by drivers undergoing renewal, etc.). Please do not include drivers already under periodic review. Provide the number of non-alcohol-related cases, followed by the number of alcohol related cases. If it is not possible to distinguish between alcohol and non-alcohol-related cases, enter the total number of cases referred only.

Number of non-alcohol cases: Click here to enter text.

Number of alcohol-related cases: Click here to enter text.

Total number of cases: Click here to enter text.

Comments about any of the above counts: Click here to enter text.

27. How many cases that were already under periodic review, did the Licensing Agency’s Medical Review Department review in 2012? Provide the number of non-alcohol-related cases, followed by the number of alcohol related cases. If it is not possible to distinguish between alcohol and non-alcohol-related cases, enter the total number of cases reviewed only.

Number of non-alcohol cases: Click here to enter text.

Number of alcohol-related cases: Click here to enter text.

Total number of cases: Click here to enter text.

Comments about any of the above counts: Click here to enter text.

28. What were the sources of the initial non-alcohol-related referrals/letters of concern in 2012, and what percentage of the total number of these referrals does each source represent? Check all that apply and enter a percent. Also check whether these percentages are actual data (strongly preferred) or if they are your best estimates (if your State does not track referrals by source).

☐ Actual Data OR ☐ Estimates

☐ Law Enforcement: Click here to enter text.

☐ Court: Click here to enter text.

☐ Physician: Click here to enter text.

☐ Driver Self-Report (including response to questions on license application/renewal form): Click here to enter text.

☐ DMV examiner or licensing office staff (following observation of potential impairment): Click here to enter text.

☐ Department of the Blind and Visually Impaired: Click here to enter text.

☐ Family Member: Click here to enter text.

☐ Other Concerned Individual: Click here to enter text.

28a. Please list any other initial non-alcohol-related referral sources not listed above, and provide a percentage for each: Click here to enter text.

29. Are first-time applicants for a passenger vehicle driver’s license required (by State statute or law) to have a physical exam performed by a physician or other medical practitioner (apart from whether a driver license examiner observes signs of impairment or a driver self-reports a medical condition)? (Check 1 response).

☐ Yes (please provide reference to statue or law): Click here to enter text.

☐ No

☐ No, except for older drivers (enter age): Click here to enter text.

30. Are driver license applicants required to respond to either written or verbal questions about medical conditions? (Check only 1 response)

☐ Yes, for first-time applicants only

☐ Yes, for renewal applicants only

☐ Yes, for first-time and renewal applicants

☐ No

31. Are physicians required by law to report drivers to the Licensing Agency who have medical conditions or functional impairments that could affect their ability to drive safely?

☐ Yes

☐ No (if “No,” skip to question # 32)

If “Yes” to Question # 31:

31a. Describe the conditions or situations that physicians are required to report: Click here to enter text.

31b. If a physician fails to report a driver with a medical condition, as required, and then the patient is involved in a crash, can the physician be held liable as a proximate cause of a crash resulting in death, injury, or property damage caused by the patient?

☐ Yes

☐ No

31c. If a physician fails to report a driver with a medical condition, as required, can the physician be convicted of a summary criminal offense (Note: In Pennsylvania, a summary offense is an offense dealt with in District Court. Some of the most common types of summary offenses include disorderly conduct, harassment, criminal mischief, first offense shoplifting and underage drinking. Many violations of the Motor Vehicle Code are also characterized as summary offenses. Some include speeding, running a red light and illegal parking).

☐ Yes

☐ No

32. For physicians who report drivers to the Licensing Agency (either by law or on a volunteer basis), are reports confidential? (Check 1 response).

☐ Yes, without exception

☐ Yes, except in the following conditions (Check which apply):

☐ Driver may receive copy upon request

☐ When requested for judicial action

☐ Other (describe): Click here to enter text.

☐ No

33. Are physicians who report drivers in good faith (either by law or on a volunteer basis) immune from legal action by their patients? (Check 1 response).

☐ Yes, for all conditions

☐ Yes, but only if report is for a condition required by law to be reported

☐ No

34. Does the Licensing Agency accept reports from individuals who do not provide their name (i.e., anonymous referrals)?

☐ Yes

☐ No

35. Are reports from any of the sources investigated before the Licensing Agency contacts a driver for possible evaluation (to authenticate the need for a medical review and rule out malicious intent in reporting)?

☐ Yes

☐ No (if “No,” skip to Question # 36)

35a. If “Yes” to Question # 35, which sources are investigated, and what is the investigation process?

Click here to enter text.

36. Are all drivers undergoing initial Medical Review/reexamination required to submit a medical report completed by their treating physician(s) and/or a vision report completed by their vision specialist to the Licensing Agency as a part of the Medical Review Process?

☐Yes (if “Yes,” skip to Question #37)

☐No

36a. If the answer to Question # 36 is “No,” please describe the circumstances under which a driver would not be required to comply with this step in the Medical Review/reexamination process.

Click here to enter text.

37. Which of the following types of guidelines/medical standards does your State apply for licensing drivers of passenger vehicles? Remember, this survey concerns drivers of passenger vehicles only (includes cars, vans, and pick-up trucks only); it does NOT include commercial motor vehicle drivers or school buses or other for-hire passenger transport. (Check all that apply)

☐ Vision

☐ Seizures, loss of consciousness or bodily control

☐ Alzheimer’s Disease/Dementia

☐ Other medical conditions (may include one or more of the following: cardiovascular, cerebrovascular, endocrine conditions, respiratory conditions, neurological disorders, musculoskeletal disorders, psychiatric disorders)

38. When a driver must provide a medical form from his or her treating physician, what opinions does the Licensing Agency request the driver’s treating physician to provide on the form? (Check all that apply):

Whether, in the treating physician’s opinion, the patient is medically safe to operate a motor vehicle

☐ Whether and what types of DMV tests (knowledge, vision, road) should be given

☐ Whether the patient should undergo evaluation by a Driver Rehabilitation Specialist to determine safe driving ability

☐ Whether and what types of driving restrictions should be applied to the license

☐ Whether and how frequently the driver should undergo periodic review

☐ None of the above - the Licensing Agency requests only medical history

39. When Licensing Agency case reviewers or medical review board physicians are evaluating medical information provided by a driver’s physician (forms requested for completion by the DMV), what do the case reviewers or physicians consider when making a licensing determination? Check all that apply.

☐ Current diagnosed medical conditions

☐ Effects of medications, driver-impairing side effects, and medication interactions

☐ Conformance with Department medical guidelines for licensing

☐ Treating physician’s opinion on fitness to drive

☐ Other (explain): Click here to enter text.

40. Do drivers undergo in-person screening of physical and cognitive abilities as part of a medical re-examination (apart from the standard DMV vision, knowledge, and road tests)?

☐Yes

☐No (if “No,” skip to Question 41)

If “Yes” to Question 40:

40a. Describe who conducts these tests (e.g., front line/counter personnel, driver license examiners, hearing officers, physicians or nurses on case review staff, MAB physicians, etc.): Click here to enter text.

40b. Describe the kinds of tests and how they are administered (e.g., computerized battery of tests or paper and pencil tests measuring executive functioning, selective attention, divided attention, presence and degree of mild cognitive impairment or dementia; physical performance measures such as walking speed, trunk/arm/leg flexibility and range of motion, etc.) Click here to enter text.

41. Is there a method or process used by the Medical Review department to prioritize particularly risky cases (i.e., a “triage system”) so they are processed first or more quickly than less risky cases (e.g., drivers must appear for reexamination testing in 5 days)?

☐Yes

☐No (if “No,” skip to Question 42)

41a. If “Yes” to Question 41, describe the procedures when a particularly risky driver is referred to the Licensing Agency for medical review/reexamination. Click here to enter text.

42. Are there situations where a potentially high-risk driver’s license is suspended or revoked immediately (upon receipt of a referral for medical review/reexamination), pending the outcome of the medical review process?

☐Yes

☐No (If “No,” Skip to Question # 43)

42a. If “Yes” to Question # 42, please describe the types of situations where a potentially high-risk driver’s license would be suspended or revoked immediately: Click here to enter text.

43. Which bests describes the on-road test given to drivers undergoing medical review/re-examination, when a Licensing Agency road test is required? (Check 1 response).

☐ Same on-road test given to original/novice license applicants

☐ Standard on-road test, but more comprehensive than the on-road test given to original/novice license applicants (e.g., longer, covering more situations, more discussion between examiner and customer).

☐ A specialized road test, tailored to evaluate whether a driver can accommodate his or her functional/medical impairments

☐ Other (describe, if none of the above accurately describe on-road test): Click here to enter text.

44. Which best describes the Driver License Examiners who conduct reexamination tests for drivers undergoing medical review, and their training for conducting reexaminations?

☐ The same examiners who conduct such tests for original/novice applicants (with no special training for reexamination tests)

☐ The same examiners who conduct such tests for original/novice applicants (with no special training for reexamination tests, but a higher degree of experience performing testing)

☐ The same examiners who conduct such tests for original/novice applicants (all Examiners are trained to conduct reexamination tests)

☐ More experienced or qualified Examiners with specialized training in conducting road tests for older or medically/functionally-impaired drivers

☐ Other, if none of the above are accurate descriptions (please describe):Click here to enter text.

45. Are home-area tests sometimes offered to drivers undergoing Medical Review, to determine whether a driver can navigate safely in a familiar area near home, and to determine whether a limited license can be issued (e.g., x mile radius from home, limited to specific destinations/trip purposes like shopping, doctor’s appointments, church).

☐Yes

☐No (If “No,” skip to question # 46)

45a. If “Yes” to Question 45, describe the circumstances under which a home-area test is given, the qualifications of the Driver License Examiners who conduct home-area tests, and the approximate number of home-area tests given in a 1-year period. Click here to enter text.

46. Are some drivers required to undergo evaluation by a driver evaluation specialist (e.g., Occupational Therapist or Driver Rehabilitation Specialist [DRS] outside of the Licensing Agency) to obtain this specialist’s opinion regarding fitness to drive, before a licensing decision will be made?

☐Yes

☐No

MEDICAL REVIEW OUTCOMES

47. Under what circumstances might a driver’s license be suspended/revoked/denied during the review process? Check all that apply:

☐ Referral information (i.e., the letter or form indicating cause for concern/request for reexamination) indicates loss of consciousness or other severe risk to safe driving. (Note: if it depends on referral source, please comment ): Click here to enter text.

☐ Failure to submit medical or vision reports requested by the Licensing Agency

☐ Unfavorable medical or vision report (physician or eye care specialist indicates that the severity of the condition precludes safe operation of a motor vehicle)

☐ Failure to take required Licensing Agency tests

☐ Failure on Licensing Agency tests

☐ Unfavorable evaluation by Driver Rehabilitation Specialist

☐ Disqualification based on Licensing Agency visual criteria for licensing

☐ Disqualification based on Licensing Agency medical criteria for licensing

☐ Other (explain): Click here to enter text.

48. What are the potential outcomes of referrals for medical review/reexamination (i.e., outcomes the Licensing Agency applies after review of any required medical reports and/or any required testing)? Check all that are allowed by law/administrative statute (column 1), check all that are actually applied (column 3), and for all that are actually applied, enter the percentage each outcome represents of the total number of referrals per year in column 4. The percents in column 4 should add up to 100%. Your Licensing Agency may or may not track such data, so if the percentages you enter in column 4 are based on data, check the “data based” box at the top of the column. If you estimated the percents in column 4, check the “estimated” box.

Allowed by Law or Administrative Statute	Potential Outcomes of Medical Reexaminations	Actually Applied	Percentage of all outcomes (if actually applied). Check if the percents you enter are: ☐ Data based or ☐Estimated
☐	No change in license status (no new license action taken)	☐	Click here to enter text.
☐	Suspension/Revocation /Denial	☐	Click here to enter text.
☐	Restriction to driving only during daytime/no nighttime driving	☐	Click here to enter text.
☐	Restriction to driving during specified time of day (e.g., no rush hour; or no driving 6 am-9 am and 4 pm-7 pm)	☐	Click here to enter text.
☐	Restrictions to a specified radius of home	☐	Click here to enter text.
☐	Restrictions to specific destinations in driver’s familiar area (e.g., church, doctor, grocery store, pharmacy)	☐	Click here to enter text.
☐	Restriction to a designated route	☐	Click here to enter text.
☐	Restrictions to a specific geographic area (e.g., city, town)	☐	Click here to enter text.
☐	Speed restrictions (e.g., max speed 45 mph)	☐	Click here to enter text.
☐	Road type restrictions (e.g., no freeways/limited-access highways/no 55 mph or higher-speed roadways)	☐	Click here to enter text.
☐	Corrective lenses required	☐	Click here to enter text.
☐	Adaptive equipment required (e.g., steering wheel spinner knob, hand controls, left-foot accelerator)	☐	Click here to enter text.
☐	Prosthetic aid required	☐	Click here to enter text.
☐	Restriction to drive only with a licensed driver rehabilitation specialist for remediation of driving problems, including driver training in the use of adaptive equipment and how to compensate for impairing conditions	☐	Click here to enter text.
☐	Periodic review	☐	Click here to enter text.
☐	Other (explain): Click here to enter text.	☐	Click here to enter text.

49. With the understanding that the Licensing Authority has the final authority for making a licensing determination, on what basis are licensing decisions generally made? (Check all that apply). If many apply and there is a hierarchy, rate each in order of priority in the medical review process, with “1” being most important, “2” second most important, etc.

☐ Licensing Agency generally adheres to MAB’s recommendations Click here to enter text.

☐ Licensing Agency generally adheres to recommendations made by driver’s treating physician Click here to enter text.

☐ Licensing Agency adheres strictly to visual and/or medical standards Click here to enter text.

☐ Licensing Agency generally bases decision on whether driver passes reexam tests (e.g., road, knowledge tests) Click here to enter text.

☐ Other (explain): Click here to enter text.

Comments if clarification is needed for your responses: Click here to enter text.

50. Is the outcome of the referral communicated back to the referral source (e.g., the physician, law enforcement officer, or family member who referred the driver)?

☐Yes (If “Yes,” skip to Question # 51)

☐Sometimes, under these circumstances (describe): Click here to enter text.

☐No

50a. If the answer to Question # 50 is “No,” is this due to confidentiality laws?

☐Yes (please provide Statute or Administrative Code number): Click here to enter text.

☐No

51. What is the average and range of time (number of days) for processing medical review/reexamination cases, from the date a driver is referred until the date the licensing decision is communicated to the driver? Click here to enter text.

52. Approximately how many of the drivers undergoing initial medical review/reexamination in 2012 (total from Question # 26) appealed the Licensing Agency’s decision? Click here to enter text.

AGENCY TRAINING AND OUTREACH

53. Within the past five years has the Licensing Agency and/or MAB participated in training or outreach to any of the following audiences, about referring drivers to the Licensing Agency for medical review/reexamination (identification of functional/medical impairments that could impair safe driving performance, and how to refer)? (Check all that apply)

☐ Physicians

☐ Law Enforcement

☐ Courts/Judges

☐ Licensing Agency Staff

☐ Other (explain): Click here to enter text.

54. Does your Licensing Agency make available to older and/or medically/functionally impaired drivers Public Information & Education materials explaining the importance of fitness to drive and the ways in which different impairing conditions increase crash risk?

☐Yes

☐No (if “No,” skip to Question #55)

54a. If “Yes to question # 54, please describe how this is done (e.g., print material available as handouts at licensing offices, information posted on website, presentations, etc.)

Click here to enter text.

55. Does your Licensing Agency provide counseling to drivers with functional impairments to help them adjust their driving habits appropriately, and/or to deal with potential lifestyle changes that follow from limiting or ceasing to drive?

☐Yes

☐No (if “No,” skip to Question # 56)

55a. If “Yes to question # 55, please describe how this is done

Click here to enter text.

56. Does your Licensing Agency either refer drivers to Driver Rehabilitation Specialists (DRSs) for remediation of driving problems (may include driver training for use of adaptive equipment and how to compensate for impairing conditions) or educate drivers about how Driver Rehabilitation Specialists may help remediate driving problems (and provide a list of DRSs in the area)? (Check all that apply, and comment as needed to clarify response)

☐Yes, refer drivers to DRSs: Click here to enter text.

☐Yes, educate drivers about how DRSs may help remediate driving problems Click here to enter text.

☐No

MEDICAL REVIEW COSTS

57. What is the approximate cost, financially and in staff time, to process a driver referred for medical review/reexamination where a DMV-administered on-road test is not conducted, and the case is not referred to the Medical Advisory Board? (e.g., 15 minutes of time for a medical review technician to request a medical report, review the received medical report, make the licensing decision and enter it into the system, an hourly salary of $15 = $3.75).

Click here to enter text.

58. What is the additional cost, financially and in staff time, if the case is referred to the Medical Advisory Board for review and recommendation (if your State has a Board and the Board reviews individual cases). For example: MAB physician time of 15 minutes at a cost of $50 per hour = $12.50; plus 15 minutes of DMV case reviewer time to assemble case files to present to the MAB physician = $3.75; for a total of $16.25.

Click here to enter text.

59. What is the additional cost, financially and in staff time, if the driver must undergo DMV road testing? (e.g., 1 hour at a Driver License Examiner cost of $22/hour = $22).

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60. What is the additional cost, financially and in staff time, if a driver appeals the licensing action? (e.g., 15 minutes for a technician to copy the files at an average salary of $15 hour, plus 30 minutes of a hearing officer’s time at a salary of $22/hour, plus 15 minutes of MAB physician review at $50/hour =$27.25 total).

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61. Does your Licensing Agency use an electronic medical record system (i.e., a digital version of a paper chart that contains all of the requested medical history)?

☐Yes

☐No

If “Yes:”

61a. How long are records retained (before they are archived): Click here to enter text.

62. Would your licensing agency be willing to cooperate with NHTSA in the performance of a detailed examination of medical review/reexamination records (de-identified) to better characterize medical review processes (e.g., proportion of referrals by source, reasons for referral, medical report requirements, testing requirements, licensing outcome)?

☐Yes

☐No

63. If any of your answers require more detail, please enter the question number here, and elaborate or clarify your response as needed: Click here to enter text.

Thank you very much for your time and effort in providing responses to this survey

NHTSA Form 1228 Page 21