Form P-142R "Respiratory Diseases" - Connecticut

What Is Form P-142R?

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-142R 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-142R "Respiratory Diseases" - Connecticut

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RESPIRATORY DISEASES
DRIVER'S LICENSE NUMBER
STATE OF CONNECTICUT
P-142R Rev. 11-2017
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
-
Address incident of
-
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
The patient named below has been referred to the DMV Driver Services Division concerning their ability to safely operate a motor vehicle. This medical
report must reflect the results of the medical professional's (licensed physician, PA or APRN) personal examination of the patient performed within 90 days
of this report being filed. It must be signed by the patient authorizing the medical professional to release this report and any attachments to DMV.
PATIENT'S SIGNATURE
DATE
I hereby authorize the medical professional completing and signing this medical report
to release such report to DMV along with any other medical information necessary to
X
determine my fitness to safely operate a motor vehicle.
PATIENT'S NAME (Please Print)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
(Street)
(City)
(State)
(Zip Code)
PATIENT'S ADDRESS
DATE OF LAST EXAMINATION
HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?
ABNORMALITIES ON RESPIRATORY EXAMINATION
Please explain:
ASTHMA
CHRONIC OBSTRUCTIVE
OTHER:
PULMONARY DISEASE (COPD)
SLEEP APNEA
IF YES, COMMENT AS TO PROGRESS
IS THIS A PROGRESSIVE ILLNESS?
YES
NO
IF YES, SPECIFY
ARE THERE ANY SPECIAL AID(S)/DEVICE(S) THAT MUST BE
YES
NO
UTILIZED WHILE PATIENT IS OPERATING A MOTOR VEHICLE?
IS THIS PATIENT ABLE TO EXHALE 1000CC OF AIR IN ONE
IF NO, SPECIFY
NO
CONTINUOUS BREATH DURING THE OPERATION OF AN
YES
IGNITION INTERLOCK DEVICE (IID)?
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK
DO YOU BELIEVE THIS PATIENT TAKES
POSED BY HIS/HER CONDITION(S) WHICH MAY AFFECT
YES
NO
YES
NO
MEDICATIONS AS PRESCRIBED?
HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
NO
YES PLEASE EXPLAIN
IF NO OTHER CONDITION(S) SHOULD BE EVALUATED, DOES THIS INDIVIDUAL REQUIRE
YES PLEASE EXPLAIN
NO
CERTAIN RESTRICTIONS TO SAFELY OPERATE A MOTOR VEHICLE?
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT
PERIODIC REPORTING?
IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
NO
YES
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONDITION
EVERY
MONTHS FOR
YEAR(S)
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?
YES
MEDICAL PROFESSIONAL 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.
-
MEDICAL PROFESSIONAL'S NAME (Please print or type)
OFFICE ADDRESS (Include Zip Code)
-
-
TELEPHONE NUMBER
MEDICAL PROFESSIONAL'S LICENSE NUMBER
MEDICAL SPECIALTY
(
)
MEDICAL PROFESSIONAL'S SIGNATURE
DATE REPORT COMPLETED
X
RESPIRATORY DISEASES
DRIVER'S LICENSE NUMBER
STATE OF CONNECTICUT
P-142R Rev. 11-2017
DEPARTMENT OF MOTOR VEHICLES
DRIVER SERVICES DIVISION
ct.gov/dmv
CDL/PS
YES
NO
-
Address incident of
-
MAIL TO: DMV, Driver Services Division, 60 State Street, Wethersfield, CT 06161-1013
The patient named below has been referred to the DMV Driver Services Division concerning their ability to safely operate a motor vehicle. This medical
report must reflect the results of the medical professional's (licensed physician, PA or APRN) personal examination of the patient performed within 90 days
of this report being filed. It must be signed by the patient authorizing the medical professional to release this report and any attachments to DMV.
PATIENT'S SIGNATURE
DATE
I hereby authorize the medical professional completing and signing this medical report
to release such report to DMV along with any other medical information necessary to
X
determine my fitness to safely operate a motor vehicle.
PATIENT'S NAME (Please Print)
DATE OF BIRTH
TELEPHONE NUMBER
(
)
(Street)
(City)
(State)
(Zip Code)
PATIENT'S ADDRESS
DATE OF LAST EXAMINATION
HOW LONG HAVE YOU BEEN TREATING THIS PATIENT?
ABNORMALITIES ON RESPIRATORY EXAMINATION
Please explain:
ASTHMA
CHRONIC OBSTRUCTIVE
OTHER:
PULMONARY DISEASE (COPD)
SLEEP APNEA
IF YES, COMMENT AS TO PROGRESS
IS THIS A PROGRESSIVE ILLNESS?
YES
NO
IF YES, SPECIFY
ARE THERE ANY SPECIAL AID(S)/DEVICE(S) THAT MUST BE
YES
NO
UTILIZED WHILE PATIENT IS OPERATING A MOTOR VEHICLE?
IS THIS PATIENT ABLE TO EXHALE 1000CC OF AIR IN ONE
IF NO, SPECIFY
NO
CONTINUOUS BREATH DURING THE OPERATION OF AN
YES
IGNITION INTERLOCK DEVICE (IID)?
DO YOU BELIEVE THIS PATIENT UNDERSTANDS THE RISK
DO YOU BELIEVE THIS PATIENT TAKES
POSED BY HIS/HER CONDITION(S) WHICH MAY AFFECT
YES
NO
YES
NO
MEDICATIONS AS PRESCRIBED?
HIS/HER ABILITY TO SAFELY OPERATE A MOTOR VEHICLE?
ARE THERE OTHER CONDITION(S) THAT SHOULD BE EVALUATED BY ANOTHER SPECIALIST?
NO
YES PLEASE EXPLAIN
IF NO OTHER CONDITION(S) SHOULD BE EVALUATED, DOES THIS INDIVIDUAL REQUIRE
YES PLEASE EXPLAIN
NO
CERTAIN RESTRICTIONS TO SAFELY OPERATE A MOTOR VEHICLE?
DMV MAY ISSUE A LICENSE SUBJECT TO PERIODIC STATUS REPORTS CONCERNING ANY CHANGES IN CONDITION(S). DOES THIS CONDITION WARRANT
PERIODIC REPORTING?
IF YES, PLEASE INDICATE THE CONDITION(S) AND RECOMMEND MONITORING INTERVAL(S):
NO
YES
CONDITION
EVERY
MONTHS FOR
YEAR(S)
CONDITION
EVERY
MONTHS FOR
YEAR(S)
NO
CONSIDERING THIS PATIENT'S CONDITION(S), DO YOU BELIEVE THIS PERSON MAY SAFELY OPERATE A MOTOR VEHICLE?
YES
MEDICAL PROFESSIONAL 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.
-
MEDICAL PROFESSIONAL'S NAME (Please print or type)
OFFICE ADDRESS (Include Zip Code)
-
-
TELEPHONE NUMBER
MEDICAL PROFESSIONAL'S LICENSE NUMBER
MEDICAL SPECIALTY
(
)
MEDICAL PROFESSIONAL'S SIGNATURE
DATE REPORT COMPLETED
X