Section 322.126 (2), (3), Florida Statutes, provides that "Any physician, person, or agency having knowledge of any licensed driver’s or applicant’s mental or physical disability to drive...is authorized to report such knowledge to the Department of Highway Safety and Motor Vehicles... The reports authorized by this section shall be confidential... No civil or criminal action may be brought against any physician, person, or agency who provides the information required herein."

When reporting an individual whose driving ability is questionable due to some physical or mental impairment, please complete as much of the information listed below as possible:

NAME:            DATE OF BIRTH:  
ADDRESS:           CITY:                           
   Male                    Female                                                        ZIP CODE:              

DRIVER LICENSE NO.:           STATE:  

PHYSICAL OR MENTAL HANDICAPS NOTED: