General Medical Report
General Medical Report
General Medical Report
Driving instructor authority holders must meet the commercial vehicle driver standards.
Indemnity
State legislation provides legal indemnity to medical practitioners who conduct an examination and provide CPVV with an opinion
based on that examination.
birth
I certify that I have examined the above mentioned patient (who is applying for driving instructor authority) in accordance with the relevant
national medical standards for licensing of commercial passenger vehicle drivers as set out in the guidelines. In my opinion the patient (please
tick):
Meets the relevant medical criteria for an unconditional authority and requires no further assessment
Does not meet the medical criteria for an unconditional or conditional authority (provide details of criteria not met in space
over page)
Does not meet the medical criteria for an unconditional authority but may be suitable for a conditional authority based
on information noted below (provide details of criteria not met, proposed restrictions or conditions such as the requirement to wear
corrective lenses while providing the services of a driving instructor, suggestions for management and/or periodic review in space over
page)
Requires appropriate specialist assessment (provide details of type of specialist recommended/referred to in space over page)
Other
CPVV_F001_11470_18/126128_8/19_V
7
MEDICAL ASSESSMENT
(REGISTERED MEDICAL PRACTITIONER TO COMPLETE)
Details of medical criteria not met; restrictions; management plans in place/recommended; review periods and requirements for further
assessment below:
Must wear corrective lenses while providing the services of a driving instructor (tick if appropriate)
Practice address
(If not part of stamp) MEDICAL PRACTITIONER STAMP HERE
Provider number
Phone number
Signature
Date of examination
D D M M Y Y Y Y
I, the above named patient and applicant for driving instructor authoirty, declare that I disclosed my full medical history to the above mentioned
registered medical practitioner, and consent to the examining medical practitioner providing information to Commercial Passenger Vehicles
Victoria and/or VicRoads, and I understand that I shall be responsible for any medical expense incurred in connection with the compilation of
the above medical assessment.
Applicant’s signature
CPVV_F001_11470_18/126128_8/19_V
7
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