Outline
The Colorado DR 2401 form serves a crucial role in ensuring that individuals who wish to operate a motor vehicle are medically fit to do so. This form is designed for use by both drivers and their physicians, facilitating a comprehensive medical examination that assesses various health factors impacting driving ability. The form includes sections for the driver to provide personal information, such as their name, address, and date of birth, along with a statement of understanding regarding the medical evaluation. In this statement, the driver acknowledges that their physician will assess their fitness to drive and that the findings will be considered by the Department of Motor Vehicles (DMV) in any licensing decisions. The physician's section of the form requires a thorough evaluation of the patient's medical history, including conditions related to cardiovascular health, cognitive function, and any psychiatric issues that may affect driving. Physicians are guided to use their clinical judgment to determine the patient's fitness level and recommend any necessary restrictions, such as daylight driving only or the need for further testing. The form is valid for 180 days from the examination date, emphasizing the importance of up-to-date medical assessments in safeguarding public safety on the roads.
Sample - Colorado Dr 2401 Form
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DR 2401 (09/14/20)
COLORADO DEPARTMENT OF REVENUE
Division of Motor Vehicles
P.O. Box 173350
Denver CO 80217-3350
FAX: (303) 205-8301
Condential Medical Examination Report
Driver/Patient Section
Patient Last Name First Name Middle Initial
Street Address City State ZIP
Customer Identication Number (CIN) Date of Birth
Driver Statement of Understanding (Driver signature not required for DMV processing):
• My physician will conduct a medical examination to determine my tness to operate a motor vehicle safely
and responsibly.
• My physician will respond to any additional questions from the Department of Motor Vehicle (DMV).
• I understand that this form will be considered in any decision regarding the issuance of my driver license,
pursuant to C.R.S. 42-2-111 & 42-2-112.
Signature of Driver or Patient Date (MM/DD/YY)
Driver/Patient (respond to all questions below before seeing your physician)
1. How many driving trips do you make in a typical week?
2. Do any of your regular trips involve driving at night? Yes No
3. What is the one-way distance of your furthest regular trip
Miles
4. Do any of your regular trips involve speeds ≥ 55 MPH? Yes No
5. Were you pulled over by a police ofcer in the past year? Yes No
6. Were you involved in a crash as a driver in the past year? Yes No
Physician Section
Instructions: use your best clinical judgment as you REVIEW AND COMPLETE ALL SECTIONS. Base severity ratings within each category on
your overall assessment of impairment relative to the driving task. Form must be completed by the Physician (MD or DO) or Physician's Assistant
(PA). Pursuant to C.R.S. 42-2-112, no civil or criminal action shall be brought against a physician or physician assistant licensed in Colorado for
providing a written medical opinion if the physician or physician assistant acts in good faith and without malice.
Examination Date (MM/DD/YY)
(Form is valid for 180 days from date of exam)
Are you the primary care provider for this patient Yes No
If yes, how many times have you seen this patient in the past year?
If no, are you evaluating this patient for the rst time today? Yes No
If no, have you reviewed the patient's medical records? Yes No
To your knowledge, is this patient:
Aware of his or her medical diagnosis & status? Yes Somewhat No
Aware of functional impairments that may impact driving? Yes Somewhat No
Compliant with medications & basic requirements of self-care? Yes Somewhat No
Does this patient have:
Cardiovascular Disease
Yes No
Cardiac Arrhythmia
Yes No
Heart Failure
Yes No
AHA Functional Capacity (circle level if applicable)
N/A I II III IV
Need DMV Re-Examination in 1 year?
Yes No
Current Medications
To your knowledge, is this patient subject to any consistent medicine side effects or interactions that may impair driving ability?
Yes Possibly Not Likely No
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Based on my observations of this patient and information relayed to me by this individual, I, reasonably and in good faith, believe that
_______________________________________________________________________is:
Patient Name
Specialty (Required) License Number (Required) Phone Number (Required)
Street Address City State ZIP
Patient Last Name First Name Middle Initial
Cognitive, Cerebrovascular or Neurological Condition is:
Stable
Progressive
N/A
Mental Status __________________________________________________________________________________________ (list test and score)
Confusion or Disorientation Memory Loss or Forgetfulness Inattention or Distractibility
Impaired Judgment Visual-Spatial Decit Slowed Processing Speed
Cognitive Impairment Cerebrovascular Disease Neurological Condition
Alzheimer's Disease Cerebral Infarction or Stroke Brain Injury (open or closed)
Vascular Dementia Hemorrhage or Aneurysm Tumor or Malformation
Frontotemporal or Pick's Transient Ischemic Attack Parkinson's Disease
Dementia (other or unknown) Carotid Occlusion or Hypoxia Multiple Sclerosis
Combined Impairment for Driving
Check (X) Highest Level for Section
Unimpaired
(Likely t to Drive)
Very Mild
(Likely t to Drive)
Mild
(Questionable Fitness)
Moderate
(Likely Unt to Drive)
Severe
(Unt to Drive)
Consciousness, Metabolic or Respiratory Condition is:
Stable
Progressive
N/A
*Date of last event with impaired consciousness (MM/DD/YYYY): _____________________________________________
Disorder of Consciousness or Alertness*
Blackout or Syncope* Sleep Apnea or Narcolepsy Medication Effect
Chronic Sleep Deprivation Epilepsy or Seizure Disorder Dizziness or Postural Hypotension
Metabolic Condition Respiratory Condition
Diabetes (Type 1 or 2) Asthma or shortness of Breath
Thyroid Condition (Hypo or Hyper) COPD
Morbid Obesity or Fluid retention Oxygen Dependent
Combined Impairment for Driving
Check (X) Highest Level for Section
Unimpaired
(Likely t to Drive)
Very Mild
(Likely t to Drive)
Mild
(Questionable Fitness)
Moderate
(Likely Unt to Drive)
Severe
(Unt to Drive)
Musculoskeletal, Movement or Neuromuscular Condition is:
Stable
Progressive
N/A
Check All That Apply:
Arthritis (Osteo or Rheumatoid) Frailty or General Weakness Motor Neuron Disease Muscular Dystrophy
Uses Cane or Walker Paralysis - Arm Multiple Sclerosis Parkinson's Disease
Wheelchair Dependent Paralysis - Leg Restricted or Weakness - Arm Loss of Limb
Difculty Transferring Prosthesis or Brace - Arm Restricted or Weakness - Leg History of Falls
Problems with Balance Prosthesis or Brace - Leg Restricted Neck Range of Motion Other _____________________
Orthopedic or Movement
Combined Impairment for Driving
Check (X) Highest Level for Section
Unimpaired
(Likely t to Drive)
Very Mild
(Likely t to Drive)
Mild
(Questionable Fitness)
Moderate
(Likely Unt to Drive)
Severe
(Unt to Drive)
Psychiatric, Emotional or Addiction Condition is:
Stable
Progressive
N/A
Depression Bipolar Mood Disorder Psychosis or Schizophrenia Alcohol Abuse or Addiction Drug Abuse or Addition
Suicidal or Homicidal Anxiety or Post-Traumatic Stress Chronic Pain (causing distress) Other ______________________________
Combined Impairment for Driving
Check (X) Highest Level for Section
Unimpaired
(Likely t to Drive)
Very Mild
(Likely t to Drive)
Mild
(Questionable Fitness)
Moderate
(Likely Unt to Drive)
Severe
(Unt to Drive)
Physician Name (Printed) Signature (Required) Date (MM/DD/YY)
Fit to operate a motor vehicle safely.
Fit to operate a motor vehicle safely contingent upon passing a DMV Road Test.
NOT FIT to operate a motor vehicle safely and responsibly due to signicant
medical-functional compromise or decit.
Fitness to drive determination pending; rehab permit required
Patient also requires an eye exam
Recommended license restriction(s):
Daylight Driving Only
No Highway/Freeway Driving
Hand Control
Mile Radius Only ________
Restricted MPH _________
Steering Device
Specialty Cushion
Foot Device
Automatic Transmission Only
Other_________________________
Must
Choose
One
{
DR 2401 (09/14/20)
Form Information
| Fact Name | Description |
|---|---|
| Form Purpose | The DR 2401 form is a Confidential Medical Examination Report used to assess a driver's fitness to operate a motor vehicle safely. |
| Governing Laws | This form is governed by Colorado Revised Statutes (C.R.S.) 42-2-111 and 42-2-112, which outline the requirements for medical evaluations related to driving. |
| Validity Period | The medical examination results are valid for 180 days from the date of the exam, ensuring timely assessments of a driver's capabilities. |
| Completion Requirement | The form must be completed by a licensed physician (MD or DO) or a physician's assistant (PA) to ensure professional evaluation. |
| Driver Statement | Drivers must acknowledge their understanding of the medical examination process, indicating their awareness of its implications for their driving privileges. |
| Confidentiality Clause | The form includes a confidentiality provision, protecting physicians from civil or criminal liability when providing medical opinions in good faith. |
| Patient Information | Patients must provide personal details, including their last name, first name, middle initial, address, and date of birth, ensuring accurate identification. |
| Assessment Areas | The form assesses various health conditions, including cardiovascular, neurological, and psychiatric issues, which may impact driving ability. |
Detailed Guide for Filling Out Colorado Dr 2401
Completing the Colorado DR 2401 form is a critical step in ensuring a thorough medical evaluation for driving fitness. This form requires information from both the driver and the physician. Following the steps below will help ensure that all necessary information is accurately provided.
- Begin by filling out the Driver/Patient Section at the top of the form.
- Enter the Patient Last Name, First Name, and Middle Initial.
- Provide the Street Address, City, State, and ZIP code.
- Include the Customer Identification Number (CIN) and Date of Birth.
- Read the Driver Statement of Understanding carefully. Although a signature is not required for DMV processing, it is important to acknowledge this section.
- Answer the questions in the Driver/Patient Section by selecting either Yes or No for each question.
- Proceed to the Physician Section where the physician will fill out their part.
- The physician should enter the Examination Date and assess the patient's medical conditions by checking the appropriate boxes for each condition listed.
- For each condition, the physician will indicate whether it is Stable, Progressive, or N/A.
- The physician must provide observations regarding the patient's fitness to drive, including any recommended license restrictions.
- In the Current Medications section, the physician should note any side effects that may impair driving ability.
- Finally, the physician must print their Name, sign the form, and include the Date of signing.
After completing the form, it should be submitted to the appropriate DMV office for processing. Ensure that both sections are filled out completely to avoid delays in the review process.
Obtain Answers on Colorado Dr 2401
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What is the purpose of the Colorado DR 2401 form?
The Colorado DR 2401 form is a Confidential Medical Examination Report that assesses a driver's fitness to operate a motor vehicle safely. It is primarily used by the Department of Motor Vehicles (DMV) to evaluate whether an individual meets the necessary medical standards for holding a driver’s license. The form collects information from both the driver and their physician, ensuring that all relevant health factors are considered in the licensing process.
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Who is required to complete the DR 2401 form?
The form must be completed by a licensed physician (MD or DO) or a physician's assistant (PA). The medical professional must conduct a thorough examination and provide their assessment based on the driver's medical history and current health status. It is essential that the physician uses their best clinical judgment when filling out the form.
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What information does the driver need to provide?
Before seeing their physician, the driver must answer several questions on the form. These include:
- The number of driving trips they make in a typical week.
- Whether any trips involve driving at night.
- The one-way distance of their furthest regular trip.
- Whether they have been pulled over or involved in a crash in the past year.
These questions help the physician assess the driver’s overall driving habits and potential risks.
-
How long is the DR 2401 form valid?
The form is valid for 180 days from the date of the medical examination. After this period, a new examination and form submission will be necessary for the DMV to consider the driver’s medical fitness for operating a vehicle.
Common mistakes
Filling out the Colorado DR 2401 form can be a straightforward process, but there are common mistakes that can lead to delays or complications. One frequent error is failing to answer all the questions in the Driver/Patient section. This section is crucial as it provides the physician with necessary information about your driving habits and health status. Omitting answers can result in an incomplete assessment, which may hinder your ability to obtain or maintain your driver’s license.
Another common mistake is neglecting to provide accurate personal information. This includes your full name, address, and date of birth. Inaccurate details can create confusion and may even lead to processing delays. Always double-check that all personal information matches your identification documents to avoid any issues.
People often overlook the importance of the physician's section. It must be completed thoroughly by a licensed physician or physician's assistant. If the physician fails to review the patient’s medical records or does not provide a detailed assessment, it could compromise the validity of the form. This oversight can result in the need for additional evaluations or even denial of your application.
Lastly, many individuals do not pay attention to the expiration of the form. The DR 2401 is only valid for 180 days from the examination date. If you submit the form after this period, it will not be accepted. Make sure to keep track of the examination date and submit your form promptly to ensure it is processed without delays.
Documents used along the form
The Colorado DR 2401 form is a critical document used for assessing a driver's medical fitness to operate a motor vehicle. Along with this form, several other documents and forms are commonly utilized in the process of medical evaluations and licensing. Each of these plays a unique role in ensuring that drivers meet safety standards. Below is a list of forms that are often associated with the DR 2401, providing a brief description of each.
- DR 2460 - Medical Certificate: This form is used to certify that a driver meets the medical standards required for a commercial driver’s license (CDL). It includes details about the driver's health and any medical conditions that may affect their ability to drive.
- DR 2410 - Vision Examination Report: This document is necessary to assess a driver's visual acuity and peripheral vision. It is typically completed by an eye care professional and is essential for ensuring that the driver can see adequately to operate a vehicle safely.
- DR 2395 - Driver's License Application: This is the standard application form for obtaining a driver's license in Colorado. It collects personal information, driving history, and other relevant details needed for the licensing process.
- DR 2440 - Medical Examination Report for Commercial Drivers: Similar to the DR 2401, this form is specifically tailored for commercial drivers. It requires a detailed medical examination and is crucial for maintaining safety standards in commercial driving.
- DR 2250 - Request for Re-examination: This form is used when there are concerns about a driver's ability to operate a vehicle safely. It can be initiated by law enforcement, family members, or the driver themselves, prompting a re-evaluation of their driving skills and fitness.
- DR 2411 - Driver’s Medical History Form: This form collects comprehensive medical history from the driver, including past illnesses, surgeries, and current medications. It provides the physician with essential background information for their assessment.
- DR 2310 - Road Test Application: This application is necessary for scheduling a road test for new drivers or those who need to demonstrate their driving capabilities after medical restrictions have been lifted.
- DR 2412 - Cognitive Assessment Form: This form is used to evaluate cognitive functions that may impact driving abilities. It is particularly relevant for older drivers or those with neurological conditions.
- DR 2403 - Driver's License Renewal Application: This form is required for renewing a driver's license and may include updated medical evaluations if necessary, ensuring that all drivers remain fit to drive.
In conclusion, these forms collectively support the goal of maintaining safe driving standards across Colorado. Each document serves a specific purpose, contributing to a comprehensive evaluation of a driver's fitness to operate a vehicle. Understanding these forms can help individuals navigate the process more effectively and ensure compliance with state regulations.
Similar forms
The Colorado DR 2401 form serves a specific purpose in assessing a driver's medical fitness to operate a vehicle. Several other documents share similarities with this form, each catering to different contexts but fundamentally aiming to evaluate an individual's health status in relation to driving. Below is a list of nine documents that are comparable to the Colorado DR 2401 form:
- DMV Medical Evaluation Form: Similar to the DR 2401, this form is used by various states to assess a driver's medical condition and its impact on their ability to drive safely.
- Driver Fitness Review Form: This document is often utilized by state agencies to review a driver's fitness based on medical evaluations and personal history, much like the DR 2401.
- Medical Examination Report for Commercial Driver Fitness: This report is required for commercial drivers and assesses their health to ensure they meet safety standards, paralleling the purpose of the DR 2401.
- Physician's Statement of Fitness for Driving: Physicians use this statement to confirm that a patient is fit to drive, echoing the medical assessment components found in the DR 2401.
- Vision Examination Report: This report focuses specifically on a driver's visual acuity and is often required alongside other medical evaluations, similar to the vision-related questions in the DR 2401.
- Functional Capacity Evaluation: This evaluation assesses an individual's physical abilities and limitations, helping to determine their fitness to drive, akin to the functional assessments in the DR 2401.
- Driver Assessment Questionnaire: This questionnaire collects information about a driver's medical history and driving habits, paralleling the questions posed in the DR 2401.
- Neurological Assessment Form: Used to evaluate cognitive and neurological conditions, this form serves a similar function in assessing potential impairments that could affect driving.
- Substance Abuse Evaluation: This document assesses an individual's history of substance use and its impact on driving ability, reflecting the comprehensive nature of the DR 2401 in evaluating various health aspects.
These documents, while varying in specific focus and detail, all share the common goal of ensuring that individuals are medically fit to drive, thereby promoting road safety for everyone.
Dos and Don'ts
When filling out the Colorado DR 2401 form, it is crucial to follow specific guidelines to ensure accuracy and compliance. Here are six essential do's and don'ts to consider:
- Do provide accurate personal information, including your full name and address.
- Do answer all questions honestly, especially regarding your medical history and driving habits.
- Do ensure that your physician completes the medical examination section thoroughly.
- Do sign and date the form where required to validate your submission.
- Don't leave any sections blank; all questions must be addressed.
- Don't submit the form without reviewing it for errors or omissions.
Misconceptions
Misconceptions about the Colorado DR 2401 form can lead to confusion regarding its purpose and requirements. Here are ten common misunderstandings:
- Only doctors can fill out the form. The DR 2401 can also be completed by Physician Assistants (PAs) who are licensed in Colorado.
- The form is optional. This form is required for the DMV to assess a driver’s fitness to operate a vehicle safely, particularly if there are medical concerns.
- It only applies to older drivers. Any driver with medical conditions that may affect their ability to drive safely must complete this form, regardless of age.
- Submitting the form guarantees a driver's license. Completion of the form does not ensure that a driver will receive or retain their license; it is just one part of the evaluation process.
- Medical information is not confidential. The information provided on the DR 2401 is confidential and protected under privacy laws.
- It can be filled out after the medical examination. The form must be completed during the medical examination, as it relies on the physician's assessment at that time.
- Only physical health is evaluated. The form assesses various conditions, including cognitive, psychiatric, and neurological issues that may impact driving ability.
- Drivers cannot contest the physician's decision. Drivers have the right to seek a second opinion or contest the recommendations made by their physician.
- It has no expiration. The DR 2401 form is valid for only 180 days from the date of the examination, after which a new evaluation is needed.
- All drivers must undergo a physical exam every year. Only those drivers with specific medical conditions or concerns will be required to submit the DR 2401 form for re-evaluation.
Key takeaways
Here are key takeaways regarding the Colorado DR 2401 form:
- The form is used to assess a driver's medical fitness to operate a motor vehicle.
- It must be completed by a licensed physician (MD or DO) or a Physician's Assistant (PA).
- Patients should answer all questions in the Driver/Patient section before seeing their physician.
- Physicians should use their clinical judgment when evaluating the patient's fitness to drive.
- The form is valid for 180 days from the date of the medical examination.
- Patients may need to provide information about their medical history, including any conditions that could affect driving.
- License restrictions may be recommended based on the physician's assessment.
- Confidentiality is maintained, and physicians are protected from civil or criminal actions when acting in good faith.