Missouri's Driver License Bureau takes reports on this two-page form from listed professionals and immediate family who have firsthand knowledge of a driver they believe can no longer drive safely. After review, the Director of Revenue may require the driver to take a medical, vision or driving test. Physicians who file it attach Form 1528.
The reporter completes the entire form, including driver details, observed driving behavior, any medical conditions and the signed declaration on the reverse. Physicians also complete and attach Form 1528, the Physician's Statement.
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Driver Condition Report
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Form 4319 must be completed by a physician, chiropractor, registered nurse, psychologist, optometrist, physical or occupational therapist, social worker, professional counselor, emergency medical technician, law enforcement officer, or immediate family member of the driver. In-laws are excluded from the immediate family list.
Yes. The form states that all information in the report is kept confidential unless released by a court order. The reporter still signs under penalties of perjury, and intentionally filing a false report is a Class A misdemeanor with liability for resulting damages.
Yes. Page 2 of Form 4319 asks physicians to complete Form 1528, the Physician's Statement, and attach it to the report. Form 1528 rates impairment by domain and records the physician's conclusion on whether the patient can drive safely.