Pennsylvania providers report a driver's seizure disorder or epilepsy to PennDOT on this condition-specific form, which documents the seizure-free interval and any waiver request under 67 Pa. Code 83.4. PennDOT uses it to decide whether the driver meets the state's medical standards and can keep driving, needs restrictions, or must have the license recalled.
The treating physician or other health care provider completes the entire form, including the seizure history and any waiver request.
Download the current version from the source each time; forms change without notice.
Seizure Reporting Form
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Yes. PennDOT's forms page points out that 67 Pa. Code 83.4(c) requires providers who treat a person who has experienced a single seizure to report that individual to the Department. DL-121 is the condition-specific form for seizure disorder and epilepsy.
The treating physician or other health care provider completes the entire form. Pennsylvania's reporting duty applies to physicians, chiropractors, physician assistants and certified registered nurse practitioners, who must report in writing within 10 days, and health care personnel need PennDOT credentials to open the PDF.
PennDOT reviews reports within 15 days. It may take no action, place a restriction, require more medical information from the driver within 45 days, order a driver's exam, or recall the license until medical competency is demonstrated.