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Utah DLD 134 Functional Ability Evaluation Report

Utah's Driver License Division uses this report to place a driver on its functional ability scale for each medical condition that affects driving. The health care professional rates categories A to K, from diabetes and cardiovascular disease to mental health, substance use and sleep disorders, on levels 1 to 8, then recommends a review time frame, restrictions and any driver testing. Level 8 means no driving.

Who completes it

The driver completes and signs the top block; a health care professional completes everything after it, and a second HCP can add ratings and a signature on the second line.

Submitting and payment

How to submit it
Submit through the DLD Medical Portal, the preferred route, where forms may be added the same day, or by email, fax or mail; email and fax take 2 to 3 business days, and reports older than 6 months are rejected.

Good to know

  • Page 2 condenses Utah's Functional Ability in Driving guidelines, with each level's criteria and default review interval; the HCP's own recommendation supersedes those defaults.
  • Restrictions offered: roads posted 40 mph or less, supplemental oxygen while driving, an area restriction that requires a driving review, and daylight driving only.
  • Category K uses the Epworth Sleepiness Scale; for example, level 1 means no history or problem for two years and an ESS below 6.
  • A submission is rejected if it is older than 6 months or missing required items such as exam date, printed name, signature and degree.

Get the official form

Download the current version from the source each time; forms change without notice.

Functional Ability Evaluation Medical Report

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

What do the levels on Utah's DLD 134 mean?

Each category runs from level 1, usually no history or fully recovered with no further review, to level 8, no driving. Levels in between set review intervals such as one year or six months, and some require a speed, area or daylight restriction or a skills test on initial assessment.

How do I submit a Utah Functional Ability Evaluation?

Utah DLD prefers its Medical Portal, where forms may be added the same day. Email and fax have a turnaround of 2 to 3 business days after receipt, and mail is also accepted. The report is rejected if it is more than 6 months old or missing required information.

Can my recommendation override Utah's standard review time?

Yes. The form states that recommendations made by the individual's health care professional supersede the standardized guidelines. The HCP can choose standard review time, review upon renewal, six months, one year, no further review, another interval, or ask to discuss special considerations.