Connecticut Guidelines for Medically at-risk Drivers

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1 Connecticut Guidelines for Medically at-risk Drivers This information package regarding the State guidelines for medically at-risk drivers in Connecticut has been compiled for DriveABLE client use only, using the sources indicated below *. Physician / medical reporting Sec states that a physician may report to the DMV in writing the name, age, and address of any person diagnosed by him to have any chronic health problem which in the physician s judgement will significantly affect the person's ability to safely operate a motor vehicle. Immunity No civil action may be brought against the commissioner, the department or any of its employees, Legal Protection Only the laws regarding immunity apply. Link to licensing authorities website section More detailed information is available in the following pages; feel free to contact us if you have a question, you will find our contact information at * Sources Lococo K, Staplin L. Strategies for Medical Advisory Boards and Licensing Review. Washington, DC: National Highway Traffic Safety Administration; Wang CC, Kosinski CJ, Schwartzberg JG, Shanklin AV. Physician s Guide to Assessing and Counseling Older Drivers. Washington, DC: National Highway Traffic Safety Administration; Any information in this document is made available for informational purposes only; DriveABLE has made reasonable efforts to ensure the accuracy of the information presented, but regulations and state guidelines may have changed. DriveABLE 2008

2 Connecticut Driver licensing agency Connecticut Department of Motor Vehicles contact information 60 State Street (within Hartford or outside CT) Wethersfield, CT (elsewhere in CT) Licensing Requirements Visual acuity Visual fields Color vision requirement Type of road test Restricted license Each eye with/without correction...20/40 Both eyes with/without correction...20/40 If one eye blind other with/without correction...20/40 Absolute visual acuity minimum...20/70 in better eye for restricted license; some circumstances allow for restricted license at 20/200 Are bioptic telescopes allowed?...no Minimum field requirement monocular; 140 binocular Visual field testing device...optec 1000 None (only for commercial drivers) The general on-the-road skills test is conducted by a DMV instructor or licensing agent. The test for a graduated license is conducted by off-site staff who make an appointment with the applicant at his/her residence and conduct the test in a state-owned, dual control vehicle. Applicants with specific needs are trained/tested by a Handicapped Driver Training Unit certified driving instructor. Graduated license considerations include the applicant's health problem/condition, accident record, and driving history. Restrictions include: daylight only, corrective lenses required, no highway driving, automatic transmission only, external mirrors required, special controls or equipment, and hearing aid required. License Renewal Procedures Standard Age-based renewal procedures Length of license validation...6 years Renewal options and conditions...in-person at DMV full-service branch, mobile unit scheduled locations, satellite offices, license renewal centers, and authorized AAA offices. Vision testing required at time of renewal?...no Written test required?...no Road test required?...only for new applicants and for these applicants whose license has been expired for two or more years. Applicants age 65+ may renew for 2 years. Applicants age 65+ may renew by mail only upon submission of a written application showing hardship which shall include but is not limited to distance of applicant s residence from DMV renewal facility. Reporting Procedures Physician/medical reporting Immunity Legal protection Sec states that a physician may report to the DMV in writing the name, age, and address of any person diagnosed by him to have any chronic health problem which in the physician s judgement will significantly affect the person's ability to safely operate a motor vehicle. No civil action may be brought against the commissioner, the department or any of its employees, the board or any if its members, or any physician for providing any reports, records, examinations, opinions or recommendations. Any person acting in good faith shall be immune from liability. Only the laws regarding immunity apply. (continued on next page) 86 Chapter 8 State Licensing and Reporting Laws

3 DMV follow-up Other reporting Anonymity The driver is notified in writing of his/her referral to the MAB. If the MAB requires additional information for review in order to make a recommendation, the driver is requested to file the additional medical information. State regulations require 'reliable information' to be on file for the DMV to initiate a medical review case. This includes a written, signed report from any person in the medical/law enforcement profession, or a third party report on the DMV affidavit which requires signing in the presence of a notary public. All information on file in a medical review case is classified as confidential. However, it is subject to release to the person or his/her representative upon written authorization from the person to release the data. Medical Advisory Board Role of the MAB MAB contact information The MAB must be comprised of 8 specialties 1. General medicine or surgery 2. Internal medicine 3. Cardiovascular medicine 4. Neurology or neurological surgery 5. Ophthalmology 6. Orthopedic surgery 7. Psychiatry 8. Optometry The MAB advises the commissioner on health standards relating to safe operation of motor vehicles; recommends procedures and guidelines for licensing individuals with impaired health; assists in developing medically acceptable standardized report forms; recommends training courses for motor vehicle examiners on medical aspects of operator licensure; undertakes any programs/activities the commissioner may request relating to medical aspects of motor vehicle operator licensure; makes recommendations and offers advice on individual health problem cases; and establishes guidelines for dealing with such individual cases. Connecticut Department of Motor Vehicles Medical Review Division 60 State Street Wethersfield, CT fax Chapter 8 State Licensing and Reporting Laws 87

4 Connecticut Organization of the Medical Program The Department of Motor Vehicles Administers driver licensing in the S tate of Connecticut. Connecticut has a Medical Advisory Board that was enacted during the 1981 session of the Connecticut General Assembly, and once codified, became Section a to 14-46g of the State Statutes. The law became effective October 1, The original statute required no less than 7 and no more than 15 medical doctors on the Board. The law was amended during the 2002 Session of the General Assembly to require no less than 8 and no more than 15 members, which shall also include an optometrist. There are presently 13 members on the Board, which will increase to 14 when an optometrist is appointed. There are also plans to add a second cardiologist. The Board is composed of the following medical professionals: 1 optometrist; 2 ophthalmologists; 1 cardiologist; 4 internal medicine physicians, specializing in family practice, emergency room medicine, endocrinology, and geriatrics; 3 neurologists; 1 orthopedic; and 2 psychiatrists. Board members are appointed by the Commissioner of Motor Vehiclesfrom a list of nominees submitted by the Connecticut State Medical Society representing specific specialties. For appointment of the optometrist, the name will be selected from a list of nominees submitted by the ConnecticutAs sociation of Optometrists. Members serve a 4-year term; the Commissioner fills any vacancy for the unexpired portion of a term. The Chair of the Board is an Ophthalmologist. Members serve voluntarily on the Board they are not employed by the DMV. Two of the Board members are retired and the balance are practicing physicians associated with hospitals, clinics, VA medical center, etc. One internal medicine member is an emergency room physician. Members are not compensated for their MAB services, but receive reimbursement for necessary expenses or services incurred in performing their duties, including the giving of testimony at any administrative hearing when requested by the Commissioner. The Board meets at the call of the Commissioner at least twice a year, but special meetings may be held to fulfill their responsibilities. Board members interact for disposition of fitness to drive cases by regular mail, on a case-by-case basis. Medical information is mailed to appropriate Board members. A driver may have more than one medical condition for which Board reviews and recommendations are needed; therefore, medical information regarding a specific driver may be referred to more than one Board member. Board members are provided with pre-paid postage DMV Medical Review Division courtesy envelopes for return mail purposes. In some cases, because of time constraints, medical information is faxed to a Board member for review and recommendations,with a request for a return fax of the Board member s response. Board members are immune from civil liability, and may not be compelled to testify in proceedings other than those relating to whether an individual meets the health standards of motor vehicle licensure regarding facts concerning the medical condition of an individual. Board meetings are open, minutes of each meeting are prepared, and copies are provided to the Board members. However, meetings held to discuss recommendations regarding an individual s fitness to drive are held in executive session. Written recommendations of the Board are classified as confidential and the Department is prohibited from releasing such information 37

5 except to the person who is the subject of the report and only upon receipt of their written authorization to release information and to whom. In addition, if an individual is aggrieved by the Hearing Officer s decision and files a court appeal, the original file is referred to the Office of the State Attorney General (who represents the Commissioner of Motor Vehicles in court proceedings) and the documents filed on behalf of the client may be taken into consideration during the court proceedings. Board members identities are generally anonymous. When satisfying a request of a client for copies of all information in his or her file, the name of the Board member is usually blocked out to avoid the possibility of the driver contacting the Board member. However, if the client requests a copy of the Board s response during the course of the hearing, the officer grants the request, and the name is not blocked out. Very rarely does the Department ever receive a request for a list of the names and addresses of Board members. The Board is engaged in a variety of activities. First, the Board advises on medical criteria and vision standards for licensing. It played a significant role in the drafting process of the regulation regarding Health Standards for Licensing Decisions for Operations of Motor Vehicles. In Connecticut, regulations are apropos to state statutes. It also played a role in the drafting process of the DMV Substance Abuse Treatment Program Regulation (effective October 1, 1995). This program requires the Department to administer such a program concerning repeat driving under the influence (DUI) offenders. DUI offenders are those who have two or more suspensions on their driving histories since 10/1/95 for alcohol-related violations or convictions. An alcohol-related violation results from a failure to pass or refusal to submit to sobriety test. An alcohol-related conviction results from driving under the influence. The Department monitors the two providers who administer the DMV Substance Abuse Treatment Program. A second type of activity in which the Board is engaged is reviewing and advising on individual cases. In this activity, the Board performs paper reviews. Forms submitted by the driver s physicians, police, family, the driving record, and (if available) results of evaluationsor assessmentsperfo rmed at rehabilitation facilities, or on-road retests are forwarded to Board members. On occasion, a Board member may find it necessary to contact a doctor who submitted medical reports on behalf of a client to explore a point of information contained within the report, so that a comprehensive recommendation can be made. The Board performs no reevaluations of drivers. Board members review the documentation referred to them, and then make recommendations to the Commissioner of Motor Vehicles. Although the recommendations are advisory only and are not binding upon the Commissioner Board recommendations play a significant role in the Department s decision-making process. A third activity in which the Board is engaged is assisting in the development of standardized, medically acceptable report forms. The Board played a significant role in the drafting process of the medical reports utilized by physicians to file on behalf of their patients. The purpose of such revisions is to ensure the presentation of more detailed medical information to the Department. A fourth activity in which the Board is engaged is the development of educational materials on driver impairment for the general public. The Board was consulted in regard to the creation of the Graduated License Program brochure which is available for distribution to the 38

6 general public. This brochure briefly explains the medical review process, on-road retesting, then issuance of a license to a client, restricted in accordance with his or her medical abilities. A fifth activity, although conducted within their own practices, is conducting or overseeing new research on medical fitness to drive. During the conduct of their private practices, Board members frequently participate in conferences and meetings with colleagues. When information regarding fitness to drive is encountered that may be of interest to the Board and Medical Review Division, the issues are discussed during the course of a Board meeting. A sixth activity of the Board is to recommend procedures and guidelines ( medical aspects ) to the Commissioner for licensing individuals with impaired health. However, statutory/regulatory aspects fall within the jurisdiction of the Department. Connecticut DMV has a Medical Review Division within the Bureau of Legal and Driver Services comprised of the following staff: 1 Motor Division Chief II; 1 Motor Vehicle Program Coordinator; 2 Motor Vehicle Driver Improvement Analysts; 1 Motor Vehicle Driver Improvement Assistant; 1 Motor Vehicle Registration Specialist; and 1 Administrative Assistant to the Division Chief. All staff members have complete knowledge of and expertise in applying State health standards for license holders, State physical standards for applicants for licenses to operate vehicles transporting passengers; and Federal standards for applicants for commercial drivers licenses. Staff have full knowledge of all State laws, and rules and regulations regarding issuance, suspension, and restoration requirements for operators licenses. When information contained within reports filed on behalf of a driver is unclear or unfavorable, the Medical Review Division refers the reports and source documents to an appropriate member of the Medical Advisory Board for review and recommendations. Approximately 1,000 cases are referred to the Board each year. Although no statistical breakdown is available regarding the ages of the referred drivers, it is estimated that 75 percent of the cases concern clients age 65 and older. Identification of Drivers with Medical Conditions and Functional Impairments Application Form Drivers with medical or functional impairments come to the attention of the DMV in a number of ways. Both first-time and renewal license applicants must sign a medical certification statement of the license application form. The original license application contains the following text: I hereby certify that I do not have any health or vision problems that prevent me from driving safely. There is no list of medical conditions on the application form to assist an applicant in self reporting a medical condition. The renewal application contains the following text: Your signature on this application attests, subject to penalties for false statement, that your driving privilege is not under suspension and that you do not have any health problems or conditions that prevent you from driving safely. If a license holder at the time of renewal advises the examiner that he or she has a medical condition, the license is renewed. In addition, the license holder is presented with medical reports depending upon what information the license holder has given the examiner. A driver may be required to have his or her physician complete 39

7 an Initial Medical Request form to determine what conditions a driver has (neurologic, ophthalmologic, cardiovascular, orthopedic, endocrine, psychiatric, alcohol/substance abuse, narcolepsy/sleep apnea, liver/renal failure, or other), followed by Medical Reports for specific diseases, as appropriate. Medical reports must be based on an examination by a physician within the previous three months. In some instances, applicantsmay not be able to meet the minimum health standards to hold an unlimited license, but may be able to meet minimum health standards for a Graduated License (i.e., a restricted license). Once the reports are filed, the medical review case is initiated and the person is subject to the medical review process. If a license holder at time of renewal fails to mention that he or she has a medical condition and merely signs the application, the license would be renewed under the normal renewal process. If it is obvious to the examiner that the renewal applicant has a medical/mental/physicalcondition, but the applicant fails to mention the fact, the license would be renewed. However, the examiner would complete and sign the Branch Office Impairment Report form, and then the examiner s immediate superior would sign and mail the report to Medical Review Division for initiation of a medical review case. Vision Screening and Vision Standards New license applicants must take a vision test, and meet the minimum standards of: 20/40 visual acuity in both eyes or the better eye with or without corrective lenses, and an uninterrupted binocular visual field of at least 140 degrees in the horizontal meridian, or a monocular field of at least 100 degrees in the horizontal meridian, and no evidence of any other visual condition(s) which either alone or in combination would significantly impair driving ability. Drivers who fail to meet the minimum standards are required to file an Eye Care Professional s Medical Report, reflecting the results of the doctor s personal examination within 90 days of the report being filed with the department. A person who has a best corrected visual acuity of worse that 20/40 but at least 20/70, an uninterrupted visual field of not less than 100 degrees in the horizontal meridian, and no other visual conditions that could significantly impair driving ability may be issued a license restricted to daylight only or as otherwise determined by the Commissioner. A person who has best corrected visual acuity better than 20/200 in the better eye, and has an uninterrupted visual field of at least 100 degrees in the horizontal meridianmay be issued a license as the Commissioner deems advisable after consideration of factors including driving ability, driving needs, and the recommendations of the person s ophthalmologist or optometrist. The person may be required to take a road test, and the opinion of the MAB may be requested to determine whether a license should be issued and what restrictions should be imposed. If a driver has a visually related health problem that may affect safe driving ability, he or she will be required to submit a Vision Report for evaluation by the Commissioner. No license will be issued to a person who has best correct visual acuity of 20/200 or worse in the better eye, or has an uninterrupted binocular visual field of less than 100 degrees in the horizontal meridian or an uninterrupted monocular visual field of less than 70 degrees in the horizontal meridian, or has any other visual condition(s) which alone or in combination will significantly impair driving ability. Connecticut does not issue licenses to drivers who use spectacle mounted telescopic aids. 40

8 A law becomes effective July 1, 2003, which requires the Department to phase in a vision screening program and requires renewal applicants to pass a vision screening every other renewal at either a DMV office or with their eyecare professional and submit a medical report to this effect when they renew. However, because of stringent budgetary issues, it is anticipated no funds may be made available to administer this law. No definitive knowledge of either repeal of this law or extension of the effective date will be available until later on in the legislative session, which ends in June. Referral Sources Physicians in Connecticut are not required by law to report drivers to the Licensing Agency who have medical conditions or functional impairments that may affect their ability to drive safely. The Agency does allow physicians and optometrists to voluntarily report drivers, as specified by Section of the Connecticut General Statutes. Physicians may report any persons diagnosed with any chronic health problem which in the physician s judgment will significantly affect the person s ability to safely operate a motor vehicle, or to have recurrent periods of unconsciousness uncontrolled by medical treatment. Any optometristmay report a person who has a vision problem which in the optometrist s judgment will significantly affect the person s ability to operate a motor vehicle safely. Case law indicates that a physician may be held responsible for failure to report a driver known to be incapable. A physician may file a DMV medical report (Initial Medical Report, Cardiology Medical Report, Diabetes Medical Report, Neurology Medical Report, Orthopedic Medical Report, Psychiatric Medical Report, or Substance Abuse Medical Report), and an optometrist may only file an Eye Care Professional s Medical Report. Hospital emergency room physicians utilize a different form. The Department also accepts reports filed by doctors on their stationary. Medical review records on file with the Connecticut DMV are confidential, and are to be used solely for the purpose of determining eligibility for operation of a motor vehicle; however, records are subject to disclosure to the driver or his or her representative, upon written request by the driver. In addition, medical reports are subject to release under a subpoena, or court order, or may be subject to release to a governmental agency in conjunction with certain investigations, as required by State or Federal law. The entire medical file may also be provided to the DMV Administrative Hearing Unit and the Connecticut State Attorney General s Office, should the driver appeal a licensing action. Physicians who report drivers in good faith are not immune from legal action by their patients. Other mechanisms for bringing a potentially unsafe driver to the attention of the Licensing Agency include the following individuals or facilities, which will be described in more detail below: police officers; the courts, family members, friends, and other citizens; hospitals; occupational and physical therapists; conservator of the person s person; other licensing jurisdictions; DMV authorized branch office personnel; Handicapped Driver Training Program administrators; and the driver himself or herself. Police officers may report a driver to the DMV using a letter or memo, or they may complete a form DMV N-105 Law Enforcement Authorization to Take Possession of Connecticut Operator s License and attachit to the confiscated license with any other reports regarding the confiscation of the license, and mail it to the DMV. Under the provisions of Section of the Connecticut State Regulations, a law enforcement officer has the 41

9 authority to take possession of a person s license when it has been determined by the officer that the person is unfit to continue to drive without endangering the safety of the public due to his or her physical or mental condition. The officer may recommend that the operator be required to submit evidence of current fitness, and or to be retested, or the officer may not recommend either. Probate courts send reports, usually in the form of letters, to the DMV regarding people who may be incompetent. Other Connecticut courts report persons who have appeared for a trial, and show evidence of a medical, physical, or mental condition that would affect their ability to operate a motor vehicle safely. The presiding judge directs the State Attorney to send a letter to the Medical Review Division. Family, friends, and other citizens fall within the third-party reporting category. For third-party reports, the Department has created an affidavit for completion, which must be signed in the presence of a notary public before being mailed to the DMV. The affidavit must be based on reporting party s personal observation of the driver, is made under oath, and subject to penalty of false statement. The Department receives reports from two hospital areas. The Emergency Room Physician s Report is a DMV form that may be completed by an emergency room physician who treats a patient, and who judges a health condition as one that will significantly affect the patient s ability to safely operate a motor vehicle. As a general rule, the conditions reported are: the person exhibits signs and symptoms of acute and chronic substance abuse; the person suffers from neurologic deficit(s) or an uncontrolled neurologic condition that precludes safe motor vehicle operation; the person suffers from recurrent episodes of unconsciousness uncontrolled by medical treatment; and other (includes vision, dementia, hypoglycemia, etc). Physicians associated with hospital clinics or departments may file a DMV medical report or submit a letter on their letterhead. Occupational and physical therapists associated with hospitals or private rehabilitation facilities usually perform driver evaluations and assessments prescribed by patients treating physicians. The Department accepts reports of evaluations and assessments when the reports contain the signed authorization(s) of either the physicians or the persons who are the subject of the evaluations or assessments to release such reports. A conservator (of the person s person, not their estate) may file a copy of the certificate of appointment bearing the raised Probate Court seal, and a letter requesting that the operator s license of the person be rescinded. If the person should make an inquiry to the Department regarding his or her operator s license, the person is referred to the conservator. A Power of Attorney is unacceptable. Other licensing jurisdictions may notify the DMV that a report has been filed with that agency indicating that a Connecticut driver may have been involved in an incident therein, and that the driver may have a medical or physical condition that affects safe driving ability. Or a licensing agency may notify Connecticut that a former resident for which they have a medical 42

10 file may be applying for a license in Connecticut, and the jurisdiction will forward information for whatever action Connecticut DMV deems appropriate. DMV branch office personnel are authorized to file an Impairment Report for Medical Review Division formwith the Medical Review Division concerning a license holderwho appears to renew the license, and exhibits obvious medical impairment. This form contains the following impairments to report: ability to walk may be impaired, as the person used either a cane, walker, or crutches, and shuffled his or her feet, or had to hang on to the wall or chairs while walking, or appeared in a wheelchair; the person appeared disoriented, couldnot understand instructions even where to write his or her name and had to be told several times to sign and where, as well as where to go to have the photo taken, and then to sit down to wait to be called when the license was ready; the person lost consciousness while in the office due to possible ; the person has a possible vision problem; or other. The final mechanism for identification of medically or functionally impaired drivers (Class 2, basic operator s license for passenger cars and light trucks) is the driver him- or herself. A private citizen may request retesting at the suggestion of an insurance carrier as a prerequisite to renewal of an automobile insurance policy, family doctor, or for his or her own satisfaction. The individual is required to undergo medical review which must be favorable, prior to being scheduled for an on-the-road retest. If the medical review is unfavorable, the person s license is withdrawn, and he or she is not eligible to take the road test. If the medical review is favorable, but the person fails the road test, the license is withdrawn for failure to pass the test. If an applicant appears at a branch office and requests an on-road retest, and the retest is conducted and failed, the person s license is collected by the examining motor vehicle inspector, who refers the retest results and the person s license to the Medical Review Division. Withdraw action for failure to pass the test is initiated. Individuals have the opportunity to participate in two more retests. If they fail the second and third retests, they must wait a year before requesting a supplemental retest, and must undergo a medical review which must be favorable prior to the retest being scheduled. It may be recommended to the person that he or she engage in a commercial driving school at his or her own expense, to have a licensed driving instructor conduct an on-road skills retraining course prior to requesting a third retest, or prior to requesting a supplemental retest if they have waited the full year. The Licensing Agency does not accept anonymous referrals. The Commissionermay initiate a medical review case based upon receipt of reliable information that there is a significant question regarding the ability of an applicant to operate a motor vehicle safely due to a medical condition or impairment. The definition of reliable information includes a written signed report from a person in the medical or law enforcement professions, or a statement signed under penalty of false statement by a person having personal knowledge. Based on the stringent language in the regulation, the Department is unable to accept anonymous complaints (letters or telephone calls), or signed letters where a vehicle s registration plate is cited but the driver of the vehicle is unknown. The DMV may perform certain checks of police or physician reports if the information submitted is incomplete (e.g., an incident or crash report is not attached to the Law Enforcement Authorization to Take Possession of Connecticut Operator s License form, or an incident is referred to in a letter, but the report is not attached) or if the physician is unfamiliar to 43

11 the Department. The Department is unable to accept a report signed by a health care professional who is other than a licensed physician or optometrist. Evaluation of Referred Drivers Procedures Drivers may be required to undergo reevaluation (in Connecticut, referred to as a medical review of their driving abilities ) based on the following circumstances: A crash with a fatality or an accumulation of crashes if the police, courts, or a physician has knowledge that a medical or physical condition may have contributed to crash involvement; upon referral to the Department by police, the courts, physicians, occupational and physical therapists, family, friends and other citizens; upon self report of a medical condition; upon observation by Licensing Agency personnel of signs of impairment; upon reapplication for a license after it has been expired for 2 years, and the person indicates he or she has medical conditions; and when a person applies for handicapped parking privileges. The processes surrounding a driver who has been referred to the Licensing Agency are described next. The DMV Medical Review Division is the sole repository for medical review functions concerning driver qualifications. This unit is staffed with the 7 individuals described earlier. Other DMV staff have ancillary roles in the medical review process. These include DMV Inspector personnel who perform the vision, knowledge, and on-road skills tests and retests; the Handicapped Driver Training Unit Inspector personnel who conduct on-road skills training/testing/retesting with special-needs clients; and DMV Hearings Officers who are parttime professionals (practicing attorneys) and conduct motor vehicle administrative hearings and render decisions. Other personnel outside of the DMV who are involved in the medical review of driver abilities include the driver s treating physician and eyecare specialist, the physicians and optometrist on the Motor Vehicle Operator s License Medical Advisory Board, and hospital/rehabilitation facilities personnel who conduct driving assessments and commercial driver training school personnel who conduct skills retraining programs. Medical reports, results of medical tests or other medical information filed on behalf of a person, recommendations of the Medical Advisory Board, and results of driving assessments/evaluations are taken into consideration by the Medical Review Division prior to scheduling a person for an on-road skills test/retest. If the medical information filed on behalf of a person is unfavorable, the person is ineligible to participate in an on-road skills test/retest, and license withdrawal action would be initiated. Thus, medical review is the first step in the evaluation of drivers referred to the Licensing Agency. Medical reports must be submitted by a driver s physician(s) within 30 days from receipt of request by the Medical Review Division. Physicians are asked to provide their opinions regarding the patient s fitness to drive and if favorable, what restrictions should be placed on the license and whether the DMV should conduct a road test to make a final licensing determination. 44

12 A vision test may be required when it is apparent upon initiation of a medical review case that a person may have a vision impairment. The person may be required to file an Eye Care Professional s Medical Report containing the results of an ophthalmologist s/optometrist s personal examination of the individual s vision within 90 days of the report being filed with the Department. If the person fails the vision screening, the retest is not conducted. A person converting an out-of-state license to a Connecticut license must take a vision test conducted by a DMV Inspector. If the person fails the screening, he or she is given an Eye Care Professional s Report for completion by an ophthalmologist or optometrist, which must be presented to the Departmentwhen he or she appears at a branch office to complete the process. If the person has a progressive eye disease, the medical report is referred to the Medical Review Division for processing. Some license holders, as a condition for obtaining or retaining their license, may be required to submit periodic medical reports regarding their vision. Each case is considered on its own merits. A person may be required to file a report every three months, six months, or annually for a number of years, or at specific intervals as long as they hold a license. On occasion, a person s treating physician or a Board physician may recommendthat a person be required to pass a knowledge test because of cognitive issues. A person converting his or her out-of-state license to a Connecticut license is usually granted reciprocal privileges, except that if it is suspected that the person has a cognitive impairment, he or she may be required to take and pass the knowledge test. Drivers diagnosed with dementia may retain a license; each case is considered on its own merits. If the medical information filed on behalf of an applicant is unfavorable, the license is withdrawn; if the medical information is favorable, but the person demonstrates that during an on-the-road retest that he or she has lost the ability to control a vehicle on the highways in today s traffic, the license would be withdrawn on the basis of failure to pass the retest. Treating physicians generally recommend that drivers with this condition be subject to medical reporting, which requires the filing of a medical report following an examination by a treating physician at certain intervals. Favorable reports are made part of the driver s medical review file. If a subsequent report is either questionable or unfavorable, the report is referred to the Medical Advisory Board for review and recommendations. Upon receipt of the Board s response, the file would be reviewed, and a decision could be made to withdraw the license for failure to meet the health standards to hold a license. The MAB could also recommend that a person be subject to medical reporting. The Commissioner may, at any time, require an on-road evaluation of any person to assist in the determination of the individual s driving ability. On-road tests/retests are conducted, and include a traffic sign test where the applicant is required to identify and comprehend traditional traffic signs and signals, pavement markings, and other forms of traffic directional signage presently utilized. The Department has three levels of on-the-road skills tests/retests. A general on-the-road skills test/retest is scheduled at a motor vehicle branch office nearest the person s residence. Such tests may be conducted by a license agent or a uniformed motor vehicle Inspector. An on-the-road skills test/retest for a graduatedlicense is conductedby Inspectors/Sergeantswho are assigned to the Department s Off-Site Testing Unit. A graduated license bears one or more restrictions that limit a person s scope of operation, and may include the following restrictions: daylight driving only, no limited access highways, corrective lenses, 45

13 automatic transmission, left and right mirrors required, special controls or equipment, and hearingaid required. DMV personnel in the Off-Site Unit contact the driver personally and arrange to meet at a convenient location, such as home or work. The test is conducted in a Stateowned vehicle by DMV personnel attired in casual business dress rather than uniforms to ease the driver during the test. An applicant s on-road skills retest will not include driving on a limited-access highway if medical documentation indicates that he or she is ineligible to drive on such highways, or if the applicant advises that there is no need or desire to drive on them. In such cases, persons passing the road test will be issued a restriction that excludes limited-access highway driving. The DMV staff of trained Inspectors possess the expertise to determine during the course of an on-road skills retest whether the person demonstrated qualifications for a full license, a restricted license, or no longer has the skills to control a vehicle in the traffic environment. A copy of the retest results are referred to the Medical Review Division for appropriate action. The third type of road test/retest is the Handicapped Driver Training Test. This test is given by one of three handicapped driver training specialists or sergeant, all who have completed certified driver training instructor training with a private vendor. Afterthe person scheduled for training/retraining is given sufficient opportunity to learn to operate a vehicle safely using the special adaptive equipment to meet his or her needs, the person is subject to the retest. If the person fails the retest, additional training may be available to the person, depending upon the circumstances of the case. Handicapped driver training Inspectors are attired in slacks and blazers, rather than traditional motor vehicle Inspector uniforms, to put the client at ease during the retraining/retesting process. In some cases, a person s treating physician may have prescribed a driving assessment or evaluation at a hospital or private rehabilitation facility, and a copy of the results will be provided to the Department. Similarly, the Board may recommend such an assessment/evaluation, or Inspector personnel conducting an on-road skills test/retest may determine that the person s cognitive abilities should be examined. The individual would be advised to contact his or her treating physician and request that the physician prescribe a driving evaluation/assessment and provide the Department with a copy of the results. When the person completes the retest scheduled by the Medical Review Department, the results are referred either by interdepartmental mail or fax to the Medical Review Department for appropriate action. If the customer passes the retest, he or she maybe eligible for restoration of the license, based on the medical condition and results of the retest. The license issued will either be a full license or a license having one or more restrictions, and licensure may be contingent upon the driver being placed on medical reporting for one or more physical conditions at certain periods of time for as long as he or she holds the license. Failure to pass the retest results in continuance of license withdrawal or initiation of license withdrawal. When medical information filed on behalf of a driver is unfavorable or questionable, the case is referred to the appropriate Medical Advisory Board member, based on the client s medical condition and the Board member s specialty. Information may be referred to more than one member, depending on the person s condition(s). The driver is notified that his or her case has been referred to the Board, and that he or she will be contacted regarding the Board s decision. 46

14 When the Medical Review Department receives the Board s response, the entire case is reviewed, and the person is notified of the licensing decision. If a Board member recommends additional medical information, the driver will be contacted and notified of the requirement to have the additional information filed by the appropriate medical professional. For example, the information submitted on behalf of a person with a substance abuse condition may be insufficient, and the Board may request results of treatment or counseling the client may have undergone, results of random specific blood or urine tests, proof of participation in self-help group therapy, etc. When the client has this information filed on his or her behalf with the Department, then the entire case is resubmitted to the Board member for reviewand recommendation. A Medical Advisory Board Response Form has been created for use by Board members as a mechanism for providing the results of the review and recommendations to the Medical Review Department. The checklist of items on the Board response form are as follows: There is no evidence of any medical condition which would adversely affect this operator s ability to operate a motor vehicle with reasonable safety. This operator s medical condition indicates that he/she should not operate a motor vehicle. This operator s medical condition indicates that he/she appears qualified to operate a motor vehicle under the following conditions: Daylight hours only. Non-limited access highway only. This operator s medical condition indicates that he/she appears qualified to operate a motor vehicle. However, he/she should submit updated medical forms at the interval indicated below. Every months for years. If other than your DMV standard specialty form is required for medical reporting purposes, please note here. Form number every months for years. This operator s ability to operate a motor vehicle is not adverselyaffected by any medical condition, however, a driving reevaluation is necessary and should be conductedby the DMV. This operator s ability to operate a motor vehicle maybe adversely affected by this medical condition, therefore a driving reevaluation is necessary and should be conductedby the DMV. I have insufficient information to make a recommendation, please see comments below. In approximately 20 percent of the cases referred to the board regarding clients age 65 and older (who account for approximately 75 percent of the cases referred to the Board), the Board recommends that the clients pass an on-road skills test prior to the client being permitted to drive. Based on the information provided, the Board may recommend that a client be considered only for a daylight only license, and/or no limited access highways, while wearing corrective lenses, using automatic transmission, etc. These recommendations are taken into consideration during the course of the on-road skills retest, as well as the Department s decisionmaking process. Treating physicians may or may not recommend licensing restrictions in the documents 47

15 they provide to the Department; the Board may make recommendations for restrictions when treating physicians fail to do so. The Board may recommend that a person no longer be permitted to drive, and although the recommendations of the Board play a significant role in the department s decisionmaking process, the final decision of whether to deny a license or to issue a license lies within the jurisdiction of the Commissioner of Motor Vehicles. The Board may recommend further testing, in the form of on-road skills testing conducted by DMV personnel, and may recommend on-road skills retesting at certain intervals as long as the license is held. Or the Board may recommend further specific medical testing in the form of updated blood/urine tests for specific reasons (alcohol or drugs) or, anti-seizure medication blood levels, EKG, EEG, etc., and the client would be contacted and requested to file reports of results of such tests under the medical reporting process. An unfavorable medical report would result in license withdrawal for medical reasons; no on-road test would be given. A favorable medical report followed by a failed skills test would result in license withdrawal for failure to pass the test. Medical Guidelines State of Connecticut Health Standards for Licensing Decisions for Operators of Motor Vehicles contains regulations that the State must follow when issuing a Class 2 license. It contains general and specific lists of information elements that the MAB may consider when making recommendations and the Department may consider when taking licensing action. General information to consider includes information about the medical condition (history of illness; severity of symptoms and prognosis; complications and co-morbid conditions;treatment and medications, effects and side effects, and person s knowledge and use of medications; results of medical tests and reports of laboratory findings; physician s medical report on functional ability including mental or emotional function; and the physician s recommendation on the degree of functional impairment); as well as the driver s basic driving needs; reports of driver condition or behavior; DMV vision and hearing screening results; DMV written, knowledge, road signs, and driving exam results; crashes caused by the medical condition; and the vision specialists report. Specific information about the following diseases and how the disease affects functional abilities needed for driving that the MAB and Department may consider is also listed in the regulations: conditions involving alcohol and drugs; conditions affecting cardiovascular function; conditions involving cerebrovascular function; conditions involving endocrine function; conditions affecting musculoskeletal function; conditions affecting neurological or neuromuscular function; conditions affecting peripheral vascular function; conditions affecting psychosocial, mental, or emotional function; conditions affecting respiratory function; and conditions affecting visual function. The Guidelines do not go beyond what types of information should be considered in making a licensing determinationfor drivers of passenger vehicles; with the exception of visual requirements, there are no specific standards listed for specific medical conditions. With regard to seizures and losses of consciousness, the Guidelines state: if a person who has experienced an episode (defined as any incident or segment of time involving altered consciousness or loss of 48

16 bodily control) within the previous 6-month period, the Commissioner will request the opinion of the Medical Advisory Board prior to making a decision with regard to licensing action. Disposition License Restrictions, Periodic Evaluations, and Remediation Licensing actions may be based on the recommendationsof a single Board member or by multiple Board members if there are multiple medical conditions for which the recommendation of multiple specialists should be sought. However, under Connecticut State statutes, the sole authority to suspend, revoke, withdraw, or issue a license on either a limited or unlimited basis rests solely within the purview of the Commissioner of Motor Vehicles. Thus, information contained within the source documents, medical reports, evaluation/assessment reports filed by hospital or private rehab facilities, results of on-road skills retests, training/retraining, and Board recommendations all play significant roles in the Department s decision-making process. When either the results of treating physicians personal examinations of clients or the recommendations of the Board are unfavorable, the Department concurs with the medical professionals recommendations and denies the license. Restrictions are recommended by drivers physicians and may be recommended by the Board, and consist of the following: daylight only, no limited access highways, corrective lenses, automatic transmission, left and right sideview mirrors, and special controls or equipment. Either the treating physician or the Board may make recommendations that a client be subject to periodic on-road skills retests (reexaminations) or medical statements (reports). Follow-up examinations and reports by physicians and vision specialists may be required for progressive or recurring conditions or when more than one medical condition exists. The Department does not refer drivers for remediation of impairing conditions, as it is unable to dictate to a person that he or she seek additional medical attention in relation to his or her health. If a person s license is withdrawnfor medical reasons, the individual is advised that he or she may request reconsideration if the medical condition should improve. The Board does not recommend remediation; treating physicians make informed decisions regarding remediation for patients. If a person fails to meet the minimum standards to hold either an unrestricted or graduated (restricted) license because of a correctable condition (e.g., cataracts, for which the person may undergo surgery), the license would be denied or withdrawal action would remain in effect. The client is advised, however, that should the condition improve, he or she may request reconsideration. If the person opts to undergo medical procedures resulting in their vision being corrected to meet standards, he or she may request reconsideration, and then updated medical reports must be filed for review and decision. If a treating physician indicates that the patient has been advised to undergo certain treatment or take medications to control a condition, and the patient has refused to abide, the Board takes this information into account when making recommendations to the Medical Review Department. Regarding recommendations for driver training, this would recommended after a first retest when performance is extremely poor or after a second retest where no improvement is shown, before the third and final retest is given. It will be recommended to the driver to undergo commercial driving school at his or her expense, and 49

17 have a certified driver instructor conduct an on-road skills retraining program before the third retest is given. A third retest will be scheduled, but if the driver fails, he or she must wait for 1 year to request a retest, and the client must undergo a medical review, which must be favorable, prior to a retest being scheduled. The Connecticut DMV administers the only State-funded handicapped driver training program in the Nation 1. Applicants whose physical impairments require use of special adaptive equipment to operate a motor vehicle safely must first undergo a medical review. The outcome of the medical review must be favorable prior to commencing the training program using the equipment to meet the individual client s needs. The training is conducted (at no cost to the applicant) by DMV staff who not only are motor vehicle inspectors, but are also certified driving instructors. State-owned passenger vehicles and one van in which special adaptive equipment has been installed are utilized during training. Private specially equipped vehicles owned by the client may be used, provided an instructor s brake has been installed in the vehicle for use by the inspector during the client s training and testing. Appeal of License Actions Aperson who is aggrieved by either the suspension/withdrawal of his or her license or denied the issuance of a new license, license renewal restrictions, or disputes restrictions placed on a license may request, in writing, an administrative hearing. If the person is aggrieved by the Hearing Officer s decision, he or she has the option to request reconsideration, in writing, within 15 days, or may file a court appeal within 30 days. The Department must abide by the judgment issued by the court. Counseling and Public Information & Education The Licensing Agency does notprovide counseling to drivers with functional impairments to help them adjust their driving habits appropriately or how to deal with lifestyle changes that follow from limiting or ceasing to drive. There is no provision in the motor vehicle laws requiring the Department to offer counseling, and the appropriation of funds to support initiation and continuity of such a program is a budgetary issue. A person who is eligible for a Graduated License receives an explanation regarding the driving restrictions to which they must abide, however. It is recommended to individuals who are no longer permitted to hold a license that they consult with their Municipal Agent for the Aging to determine what programs and assistance may be available to them. Some municipal/town governments operate a van service to meet the transportation needs of their residents. The Agency does not make Public Information and Educational materials available to older drivers that explain the importance of fitness to drive, beyond what is presented in the Connecticut Driver s Manual. The Agency has brochures that explain the Graduated Driver s License Program and the Training Services for Drivers with Physical Disabilities, but the information is program specific as opposed to providing information about the effects of aging and medical conditions on functional abilities and driving safety. 1 Marilyn Lukie, Motor Vehicle Division Chief II, ConnecticutDepartment of Motor Vehicles,S urvey Response dated February 21,

18 Administrative Issues Training of Licensing Employees The Licensing Agency provides specialized training for its personnel in how to observe applicants for conditions that could impair their ability to operate a motor vehicle. For new applicants, the issue of medical qualifications for drivers is a training subject for those motor vehicle inspectors who participate in and complete municipal police training. These individuals participate in recertification every three years. There is no special training for DMV branch office personnel who would report applicants to the Medical Review Division who have visible impairments or visual impairments detected during the applicant s attempts to sign their forms during the renewal process. The agency does not provide specialized training for driver licensing personnel relating to older drivers, per se; the staff who conduct on-road tests for applicants of new licenses or onroad retests for experienced drivers (regardless of age) who may be eligible for graduated licensesonly (because of medical or physical impairments) are veteran motor vehicle Inspectors/Sergeants involved in the testing/retesting programwho are well qualified. Staff assigned to the Handicapped Driver Training Program who train applicants to operate vehicles equipped with special adaptive equipment are trained certified driving instructors (butnot certified driver rehabilitation specialists). Medical Program Tracking System The Department does not have an automated medical record system; source documents, medical reports, and other documentation are not scanned into a system. All information is contained within a case file jacket maintained in the client s name, as original documents must be made available as exhibits for administrative hearings. Some information is entered into the client s driving history regarding action by the Medical Review Division. Upon initiation of a medical review file, a code is entered on the person s driving history that denotes the specific type of case. The Agency does use tickler file for follow-up purposes concerning clients given 30 days to comply with requirements; medical reporting notices generated and mailed on a monthly basis; etc. The Agency does not use automated work-flow systems. A person's nine-digit operator's license number, or learner's permit number (which will be converted to the person's operator's license number once the license has been issued), or nine-digit case number issued where a person does not have a license, or a non-driver identification card number (which will be converted to the person's operator's license number once the license has been issued) is the key component in a medical review case. All information forwarded to a person bears the appropriate number, which is entered into the system. Depending upon the type of case processed, letters are generated using a personal computer. The workload is separated into three groups by alphabet and each of the three on-line staff members is responsible for processing the workload assigned to them. Other duties and responsibilities are assigned to the three on-line staff on a monthly rotating basis. A follow-up tickler system is in place to proceed with 51

19 appropriate action whereby a person fails to comply with requirements and file a medical report within 30 days, or for medical reporting. At the time a medical review case is initiated, it is determined which medical reports must be filed on behalf of the person based on the information in the source document. If the medical reports filed on behalf of the person indicate the person has additional medical conditions that must be reviewed, appropriate medical reports are forwarded to the person for filing by the physician on the applicant s behalf. Upon receipt of a law enforcement officer's completed Form N-105 or other type of acceptable report and a person's confiscated license, an immediate withdrawal notice (effective the date the license is received in the Department) is mailed to the person via certified mail. Upon receipt of a report from a physician/optometrist that a person's medical condition/vision are such that they should no longer be permitted to operate a motor vehicle, a summary withdrawal notice (effective five days from the date of mailing) is mailed to the person via certified mail. The report must be signed by a licensed physician or optometrist; reports signed by health care professionals that are not licensed physicians/optometrists are unacceptable. Case file jackets are maintained in-house. In those instances where a client's license has been withdrawn for medical reasons or suspended for failure to comply and file documentation requested by Medical Review Division, but no action has occurred in that case for a period of two years, the driver's history is coded to indicate the file has been placed in off-site storage and the date. Should the person request reconsideration at a later date, the file is retrieved from offsite storage and reactivated. Barriers to Implementing More Extensive Screening, Counseling, and Referral Activities The Agency does not rely on NHTSA 402 funding to support its operation. Barriers to implementing more extensive counseling activities and referrals to activities including connections to alternative transportation include the lack of a statute requiring the Commissioner to implement such a program, as well as budget concerns. As a courtesy, a recommendation is made to clients to contact their Municipal Agent for the Aging to determine what programs may be available to them. Regarding implementing more extensive screening activities, the survey respondent indicated that there is already a system in place whereby additional medical reports are requested when medical information is needed to describe multiple medical conditions. 52

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