Form P-142ER "Hospital Er Physician's Impaired Driver Report" - Connecticut

What Is Form P-142ER?

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

Form Details:

  • Released on November 1, 2017;
  • The latest edition provided by the Connecticut 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 P-142ER by clicking the link below or browse more documents and templates provided by the Connecticut Department of Motor Vehicles.

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Download Form P-142ER "Hospital Er Physician's Impaired Driver Report" - Connecticut

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HOSPITAL ER PHYSICIAN'S
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
DEPARTMENT OF MOTOR VEHICLES
IMPAIRED DRIVER REPORT
P-142ER Rev. 11-2017
DRIVER SERVICES DIVISION
On The Web At: ct.gov/dmv
CDL/PS
YES
NO
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
INSTRUCTIONS:
Under
and address of any person diagnosed by him to have 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. Such reports shall be for the
information of the commissioner in enforcing state motor vehicle laws, and used solely for the purpose of determining the eligibility of any person to operate a
motor vehicle on the highways of this state.
PATIENT'S NAME: (Please Print or Type)
(Last)
(First)
(Initial)
DATE OF BIRTH:
PATIENT'S ADDRESS:
DATE OF EXAMINATION:
TYPE OF IMPAIRMENT:
Ophthalmologic
Alcohol/Substance Abuse
Alzheimer's/Dementia
Orthopedic
Peripheral Vascular Disease
Cardiovascular/Hypertension
Psychiatric/Emotional Disorder
Cerebral Palsy
Pulmonary/Sleep Apnea
Cystic Fibrosis
Spina Bifida
Endocrine/Glandular
Traumatic Brain Injury
Liver/Renal Failure
Other
Neurological/Neuromuscular
OTHER IMPAIRMENT OR MEDICAL CONDITION:
PHYSICIAN'S COMMENTS:
PHYSICIAN'S CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion of this report. I
swear or affirm under penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to penalties for
perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.
PHYSICIAN'S NAME: (Please print or type)
NAME OF HOSPITAL:
TELEPHONE NUMBER:
DATE OF REPORT:
PHYSICIAN'S SIGNATURE:
PHYSICIAN'S SPECIALTY:
PHYSICIAN'S LICENSE NUMBER:
STATE OF ISSUE:
HOSPITAL ER PHYSICIAN'S
STATE OF CONNECTICUT
DRIVER'S LICENSE NUMBER
DEPARTMENT OF MOTOR VEHICLES
IMPAIRED DRIVER REPORT
P-142ER Rev. 11-2017
DRIVER SERVICES DIVISION
On The Web At: ct.gov/dmv
CDL/PS
YES
NO
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
INSTRUCTIONS:
Under
and address of any person diagnosed by him to have 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. Such reports shall be for the
information of the commissioner in enforcing state motor vehicle laws, and used solely for the purpose of determining the eligibility of any person to operate a
motor vehicle on the highways of this state.
PATIENT'S NAME: (Please Print or Type)
(Last)
(First)
(Initial)
DATE OF BIRTH:
PATIENT'S ADDRESS:
DATE OF EXAMINATION:
TYPE OF IMPAIRMENT:
Ophthalmologic
Alcohol/Substance Abuse
Alzheimer's/Dementia
Orthopedic
Peripheral Vascular Disease
Cardiovascular/Hypertension
Psychiatric/Emotional Disorder
Cerebral Palsy
Pulmonary/Sleep Apnea
Cystic Fibrosis
Spina Bifida
Endocrine/Glandular
Traumatic Brain Injury
Liver/Renal Failure
Other
Neurological/Neuromuscular
OTHER IMPAIRMENT OR MEDICAL CONDITION:
PHYSICIAN'S COMMENTS:
PHYSICIAN'S CERTIFICATION: I certify that I have personally examined the above named person within the 90 days preceding completion of this report. I
swear or affirm under penalty of false statement in accordance with Connecticut General Statutes §14-110 and §53a-157b, and subject to penalties for
perjury for a deliberate false statement, that the above information and any attachment hereto is true and correct.
PHYSICIAN'S NAME: (Please print or type)
NAME OF HOSPITAL:
TELEPHONE NUMBER:
DATE OF REPORT:
PHYSICIAN'S SIGNATURE:
PHYSICIAN'S SPECIALTY:
PHYSICIAN'S LICENSE NUMBER:
STATE OF ISSUE: