Mississippi's Driver Service Bureau sends this one-page medical form to a driver with a 30-day Notice of Concern after a safety report, and also uses it after an examiner referral. The physician checks the relevant diagnoses, applies the printed seizure waiver criteria, and says whether the driver should lose the privilege immediately or needs further evaluation of driving competency.
The patient signs the authorization in Section A and fills in Section B; the licensed physician completes Section D, signs, and gives the report date and exam date.
Download the current version from the source each time; forms change without notice.
DR-11 - Initial Reporting Form (Medical Form)
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The form must come from the medical professional's office, not the driver. The DPS Medical Department page lists email or mail to the Driver Records Medical Division; check that page for the current mailing address, which differs from the one printed on the form. DR-11 arrives with the DE-26 vision form in the driver's Notice of Concern.
The form lists three: a two-year history of seizures only at night or immediately on awakening; a two-year history of a prolonged aura with sufficient warning; or six seizure-free months where the seizure occurred with a nonrecurring transient illness, toxic ingestion or metabolic imbalance. If one applies, no action should be taken on the license.
DPS says the DR-11 and DE-26 are valid for one year from the date a licensed medical professional completed them. For a driver who arrives at a license station on crutches, canes or in a wheelchair, or with an amputation, the examiner completes form DR-11A first to start the medical evaluation.