General Medical Report

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MEDICAL ASSESSMENT Applicant’s Victorian driver licence number

(REGISTERED MEDICAL PRACTITIONER TO COMPLETE)


This medical examination must be conducted in accordance with the national medical standards described in the current Assessing Fitness to Drive
Guidelines (The guidelines). These guidelines are available from austroads.com.au. The guidelines detail the examination process and the medical
criteria for fitness to drive.

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.

Criminal liability and insurance


Practitioners may be liable under civil law, in cases where a court forms the opinion that they have not taken reasonable steps to ensure that
impaired drivers drive only in circumstances that do not place them and other members of the community at increased risk. Professional
indemnity insurers are aware of the potential liability of medical practitioners and may reasonably expect medical practitioners to comply with the
national medical standards.

Conditions and restrictions


Medical practitioners may recommend conditions which may enhance driver competency or safety and allow the patient to continue to drive (eg.
corrective lenses). If you recommend a conditional licence, details of the recommended restrictions and reasons must be provided, otherwise a
conditional authority will not be considered.
For more information about conditional licences please refer to the guidelines.
If you believe that vehicle modifications are necessary (for example hand controls, left foot accelerator), or a prosthesis is necessary to drive safely,
or that a local area driving restriction is appropriate, a driver assessment will be necessary as the patient will need to demonstrate the ability to
drive safely with these restrictions.
If you have any doubts about the information required, or wish to discuss the case personally, please contact CPVV directly. CPVV may not accept a medical
certificate if it is illegible. Care should be taken to ensure that all relevant details have been completed and can be read.

Please complete all fields in BLOCK LETTERS

Applicant last name

Applicant first and


middle

name/s Date of DD / MM / YYYY

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)

Endocrinologist Sleep Neurologist


Specialist

Psychiatrist Cardiologist Occupational Therapist

Other

Commercial Passenger Vehicles Victoria


Ground Floor, 1 Spring Street, Melbourne VIC 3000
GPO Box 1716, Melbourne VIC 3001 Phone: 1800 638 802 (toll-free) cpv.vic.gov.au
September 2020

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)

REGISTERED MEDICAL PRACTITIONER DETAILS

Medical practitioner’s full name

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

DECLARATION & CONSENT OF PATIENT (Applicant to complete)

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

Date Check the form for completeness before


D D M M Y Y Y Y leaving the medical practitioner’s office.

Commercial Passenger Vehicles Victoria


Ground Floor, 1 Spring Street, Melbourne VIC 3000
GPO Box 1716, Melbourne VIC 3001 Phone: 1800 638 802 (toll-free) cpv.vic.gov.au
September 2020

CPVV_F001_11470_18/126128_8/19_V
7

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