Form DS-1 "Out-of-State Impaired Driver Program Enrollment and Status Form" - New York

What Is Form DS-1?

This is a legal form that was released by the New York State Department of Motor Vehicles - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2020;
  • The latest edition provided by the New York State Department of Motor Vehicles;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form DS-1 by clicking the link below or browse more documents and templates provided by the New York State Department of Motor Vehicles.

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Download Form DS-1 "Out-of-State Impaired Driver Program Enrollment and Status Form" - New York

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OUT-OF-STATE IMPAIRED DRIVER PROGRAM
ENROLLMENT AND STATUS FORM
Individuals convicted of an alcohol and/or drug-related offense in New York State (NYS) may substitute a qualifying out-of-state
impaired driver program for the NYS Alcohol and Drug Rehabilitation Program/Impaired Driver Program (IDP) in order to
satisfy court-ordered IDP requirements and/or to obtain a conditional driver license/privilege.
This form may also be used by Native American, U.S. Military and U.S. Veterans Administration programs that do not participate
in the New York State Office of Addiction Services and Support (OASAS) Impaired Driver System (IDS).
This document is to be completed by the qualifying program and signed by the director/coordinator, as well as the motorist, and
forwarded to the New York State Department of Motor Vehicles (NYS DMV). This form serves as an attestation that the program
meets the requirements set forth below and provides for a mechanism to track the progress of the motorist from enrollment
through the satisfaction of all requirements including treatment (if needed) and, ultimately, program completion.
Out-of-State Program Requirements:
1. The program must be approved or accepted by the state in which it is located to provide instruction to alcohol and drug
related driving offenders.
2. The program must have an educational component consisting of a minimum of 12 hours of in-person alcohol and drug
related education. On-line programs do not meet the NYS DMV requirement.
3. The program must include a screening component using a standardized written screening instrument to evaluate whether the
individual requires further evaluation or treatment.
a. If the selected program lacks a screening component, a substance use disorder assessment/evaluation must be
completed by an approved Substance Abuse and Mental Health Services Administration (SAMHSA) provider. To
locate a provider, visit the SAMHSA
website at http://findtreatment.samhsa.gov
b. Any recommended treatment must be completed before the out-of-state program provider reports a status of completion
to the NYS DMV.
SECTION 1
Verification of Enrollment
This section must be completed by an out-of-state program for offenders of alcohol or drugged driving upon
Instructions:
participant enrollment, and signed by both the program director/coordinator and participant. This form is for the exclusive use
of qualifying out-of-state programs, as defined above. If you are not sure whether an out-of-state program qualifies, please
contact the NYS Impaired Driver Program at (518) 473-7174.
This original form is to be retained by the out-of-state program. A signed copy of this document must be provided to the
participant, and a second copy sent to:
New York State Department of Motor Vehicles, Impaired Driver Program, 6 Empire
State Plaza, Room 329, Albany, NY, 12228. Fax (518) 388-1810 or Email: Impaireddriverprogram@dmv.ny.gov.
NYS DMV will verify all information submitted on this form with the identified course provider.
Please note,
PARTICIPANT INFORMATION (PLEASE PRINT)
Participant Name
Mailing Address
Date of Birth
NYS License ID #
Out-of-State License ID #
OR
Telephone #
Email Address
(
)
PROGRAM INFORMATION
Program Name
Contact Name
Address
Telephone #
Fax #
Email address
(
)
(
)
Program Start Date
Anticipated Completion Date
Are participants required to have a substance
o
o
use disorder assessment/evaluation?
Yes
No
DS-1 (5/21)
PAGE 1 OF 2
OUT-OF-STATE IMPAIRED DRIVER PROGRAM
ENROLLMENT AND STATUS FORM
Individuals convicted of an alcohol and/or drug-related offense in New York State (NYS) may substitute a qualifying out-of-state
impaired driver program for the NYS Alcohol and Drug Rehabilitation Program/Impaired Driver Program (IDP) in order to
satisfy court-ordered IDP requirements and/or to obtain a conditional driver license/privilege.
This form may also be used by Native American, U.S. Military and U.S. Veterans Administration programs that do not participate
in the New York State Office of Addiction Services and Support (OASAS) Impaired Driver System (IDS).
This document is to be completed by the qualifying program and signed by the director/coordinator, as well as the motorist, and
forwarded to the New York State Department of Motor Vehicles (NYS DMV). This form serves as an attestation that the program
meets the requirements set forth below and provides for a mechanism to track the progress of the motorist from enrollment
through the satisfaction of all requirements including treatment (if needed) and, ultimately, program completion.
Out-of-State Program Requirements:
1. The program must be approved or accepted by the state in which it is located to provide instruction to alcohol and drug
related driving offenders.
2. The program must have an educational component consisting of a minimum of 12 hours of in-person alcohol and drug
related education. On-line programs do not meet the NYS DMV requirement.
3. The program must include a screening component using a standardized written screening instrument to evaluate whether the
individual requires further evaluation or treatment.
a. If the selected program lacks a screening component, a substance use disorder assessment/evaluation must be
completed by an approved Substance Abuse and Mental Health Services Administration (SAMHSA) provider. To
locate a provider, visit the SAMHSA
website at http://findtreatment.samhsa.gov
b. Any recommended treatment must be completed before the out-of-state program provider reports a status of completion
to the NYS DMV.
SECTION 1
Verification of Enrollment
This section must be completed by an out-of-state program for offenders of alcohol or drugged driving upon
Instructions:
participant enrollment, and signed by both the program director/coordinator and participant. This form is for the exclusive use
of qualifying out-of-state programs, as defined above. If you are not sure whether an out-of-state program qualifies, please
contact the NYS Impaired Driver Program at (518) 473-7174.
This original form is to be retained by the out-of-state program. A signed copy of this document must be provided to the
participant, and a second copy sent to:
New York State Department of Motor Vehicles, Impaired Driver Program, 6 Empire
State Plaza, Room 329, Albany, NY, 12228. Fax (518) 388-1810 or Email: Impaireddriverprogram@dmv.ny.gov.
NYS DMV will verify all information submitted on this form with the identified course provider.
Please note,
PARTICIPANT INFORMATION (PLEASE PRINT)
Participant Name
Mailing Address
Date of Birth
NYS License ID #
Out-of-State License ID #
OR
Telephone #
Email Address
(
)
PROGRAM INFORMATION
Program Name
Contact Name
Address
Telephone #
Fax #
Email address
(
)
(
)
Program Start Date
Anticipated Completion Date
Are participants required to have a substance
o
o
use disorder assessment/evaluation?
Yes
No
DS-1 (5/21)
PAGE 1 OF 2
Verification of Enrollment (continued)
SECTION 1
CERTIFICATION:
I certify under penalty of law that the participant identified above has enrolled into our state’s program for alcohol or drugged
related driving offenders. I understand the NYS Impaired Driver Program education and screening criteria, as set forth in this
document, and attest that this program complies with all requirements. I understand that if the participant fails to meet any of
the requirements of the Impaired Driver Program, I will notify the NYS DMV immediately as this may result in the revocation
of the participant’s conditional driver license/privilege.
Director/Coordinator’s Name (print)
X
Director/Coordinator’s Signature
Date
AUTHORIZATION:
I consent and authorize communication between the out-of-state program for offenders of alcohol or drugged driving identified
above and NYS DMV of any information pertaining to my current and/or any past impaired driving/intoxicated offense(s).
I understand that the outcome of my participation in this program will be reported to the NYS DMV and failure to meet the
program’s requirements may result in the revocation of my conditional license or privilege. A false statement on this
application may be punishable as a crime under the New York State Penal Law.
X
Participant’s Signature
Date
SECTION 2
Verification of Program Outcome
This section must be completed by an out-of-state program for offenders of alcohol or drugged driving upon
Instructions:
completion of all program requirements, including any recommended treatment noted above, and signed by both the program
director/coordinator and participant. If the participant fails to successfully complete the program, the program director or
coordinator must notify the NYS DMV immediately.
This original form is to be retained by the out-of-state program. A signed copy of this document must be provided to the
participant, and a second copy sent to:
New York State Department of Motor Vehicles, Impaired Driver Program, 6 Empire
State Plaza, Room 329, Albany, NY, 12228. Fax (518) 388-1810 or Email: Impaireddriverprogram@dmv.ny.gov.
NYS DMV will verify all information submitted on this form with the identified course provider.
Please note,
o
I confirm that
has successfully completed this
(Client’s Name)
program (this includes any additional treatment required based on the assessment/evaluation) on
.
Date
o
confirm that
did not complete this program
I
(Client’s Name)
for the following reason:
CERTIFICATION:
I certify under penalty of law that the participant identified above has enrolled into our state’s program for alcohol or drugged
related driving offenders. I understand the NYS Impaired Driver Program education and screening criteria, as set forth in this
document, and attest that this program complies with all requirements. I understand that if the participant fails to meet any of
the requirements of the Impaired Driver Program, I will notify the NYS DMV immediately as this may result in the revocation
of the participant’s conditional driver license/privilege.
Director/Coordinator’s Name (print)
X
Director/Coordinator’s Signature
Date
DS-1 (5/21)
PAGE 2 OF 2
Page of 2