Utah drivers petitioning to remove an ignition interlock device (IID) requirement on medical grounds need this statement from a health care professional. The HCP lists the diagnoses that prevent a deep lung air sample, how long the driver has had them, the treatment plan, whether change is expected within six months and the tests that show the limitation. Spirometry and a DLD 134 must be attached.
The driver supplies name, date of birth and license number; a health care professional completes the rest and signs with degree and state license number.
Download the current version from the source each time; forms change without notice.
IID Removal Petition Physician Statement
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Reproducible spirometry, including graphs, done within the last 90 days. The statement also asks the health care professional to describe the tests conducted that demonstrate the conditions preventing a deep lung air sample.
No. A completed Functional Ability Medical Report, DLD 134, must accompany IDE 23, identifying each medical category that may affect the driver. IDE 23 adds the interlock questions about diagnoses, duration, treatment and expected change.
Despite the title, the form is completed by a health care professional (HCP), who gives the exam date, printed name, address, phone, state license number, degree, signature and date. Utah's medical guidelines for HCPs are posted on the Driver License Division's website.