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​Medical Reporting Forms

Health care personnel will need a medical reporting login credential to access the below documents. If you are a health care provider and would like to request these credentials, please click here to register.

 
Generic Initial Reporting Form 
(DL-13) (PDF)
(DL-13 - Click Here to Submit Online)
The Initial Reporting Form can be used by emergency rooms or other health care personnel who do not have access to the patient’s medical history or do not have enough knowledge about a specific medical condition to complete the appropriate form.
Vision Deficiencies
(DL-102) (PDF)
(DL-102 - Click Here to Submit Online)
§ 83.3 outlines the minimum vision standards for driving a vehicle and §71.3(b)(1) outlines the minimum vision standards for school bus drivers. Refer to the below links to Chapters 83 & 71 for a comprehensive list of the minimum vision standards.
 

 
Condition Chapter 83 - Medical Regulations for Drivers, other than School Bus Drivers
Cardiovascular 
(DL-120)
(DL-120 - Click Here to Submit Online)
§ 83.5(a)(2) states that a person who has cerebral vascular insufficiency or cardiovascular disease which, within the preceding 6 months, has resulted in syncopal attack or loss of consciousness, vertigo, paralysis or loss of qualifying visual fields will not be qualified to drive. § 83.5(b)(4) states that a provider may recommend a license recall if a person has cerebral vascular insufficiency or cardiovascular disease which, within the preceding 6 months, has resulted in lack of coordination, confusion, loss of awareness, dyspnea upon mild exertion or any other sign or symptom, which impairs the ability to control and safely operate a motor vehicle.
Cognitive Impairment
(DL-131)
(DL-131 - Click Here to Submit Online)
§ 83.5(b)(5) and (8) states that a provider can disqualify someone from driving if the provider feels the individual has a mental disorder manifested by the symptoms of inattentiveness to the task of driving because of, for example, preoccupation, hallucination or delusion; contemplation of suicide, as may be present in acute or chronic depression or in other disorders; excessive aggressiveness or disregard for the safety of self or others or both, presenting a clear and present danger, regardless of cause or any other condition that could impair a person's ability to drive safely.
Diabetes Mellitus
(DL-122)
(DL-122 - Click Here to Submit Online)

Reporting Drivers with Diabetes Mellitus Frequently Asked Questions
§ 83.5(a)(1) states that a person who has unstable diabetes mellitus leading to severe hypoglycemic reactions or symptomatic hyperglycemia will not be qualified to drive, unless there has been a continuous period of at least 6 months free from a disqualifying episode.

Individuals who have had a disqualifying episode and are eligible for restoration must submit to follow-up diabetic examinations, which include an HbA1C test as well as a vision screening at 6, 12, 24, and finally 48 month intervals. Diabetic examinations may be required more frequently if recommended by the treating heath care provider.

However, a waiver from disqualification may be granted if an individual has been previously free from severe hypoglycemic reactions or symptomatic hyperglycemia for the preceding 6 months and the subsequent severe hypoglycemic reaction or symptomatic hyperglycemia occurred
  • while the individual was under the treating health care provider’s care,
  • during or concurrent with a nonrecurring transient illness, or
  • toxic ingestion or metabolic imbalance.
The above waiver will only be granted if the treating health care provider submits written certification indicating it is a temporary condition or isolated incident not likely to recur.
Loss of Attention or Awareness of Unknown Etiology
(DL-129)
(DL-129 - Click Here to Submit Online)
§ 83.5(b)(6) states that a provider can disqualify someone from driving if the provider feels the individual has periodic episodes of loss of attention or awareness, which are of unknown etiology or not otherwise categorized, unless the person has been free from episode for the year immediately preceding, as reported by a licensed physician.
Loss of Consciousness of Unknown Etiology
(DL-129)
(DL-129 - Click Here to Submit Online)
§ 83.5(a)(3) states that a person who has periodic episodes of loss of consciousness which are of unknown etiology or not otherwise categorized, unless the person has been free from episode for the year immediately preceding will not be qualified to drive.
Neurological 
(DL-124)
(DL-124 - Click Here to Submit Online)
§ 83.5(b)(8) states that a provider can disqualify someone from driving if the provider feels the individual has a medical condition that could impair a person's ability to drive safely
Orthopedic
(DL-126)
(DL-126 - Click Here to Submit Online)
§ 83.5(b)(1), (2), and (3) states that a provider can disqualify someone from driving if the provider feels the individual has a loss of a joint or extremity as a functional defect or limitation; an impairment of the use of a joint or extremity as a functional defect or limitation, if the condition has lasted or is expected to last longer than 90 days; rheumatic, arthritic, orthopedic, muscular, vascular or neuromuscular disease, if the condition has lasted or is expected to last longer than 90 days.
Other conditions that affect safe driving
(DL-123)
(DL-123 - Click Here to Submit Online)
§ 83.5(b)(8) states that a provider can disqualify someone from driving if the provider feels the individual has any condition(s) which, in the opinion of a provider, is likely to impair the ability to control and safely operate a motor vehicle.
Psychiatric 
(DL-104)
(DL-104 - Click Here to Submit Online)
§ 83.5(b)(5) states that a provider can disqualify someone from driving if the provider feels the individual has a mental disorder manifested by the symptoms of inattentiveness to the task of driving because of, for example, preoccupation, hallucination or delusion; contemplation of suicide, as may be present in acute or chronic depression or in other disorders; excessive aggressiveness or disregard for the safety of self or others or both, presenting a clear and present danger, regardless of cause.
Seizure Disorder/Epilepsy
(DL-121)
(DL-121 - Click Here to Submit Online)
§ 83.4(a) states that a person who has a seizure disorder will not be qualified to drive unless a licensed physician reports that the person has been free from seizure for at least 6 months immediately preceding, with or without medication. A person will not be disqualified if the person has experienced only auras during that period. In addition, § 83.4(b) allows a physician to request a waiver if the individual has a strictly nocturnal pattern of seizures or a pattern of seizures occurring only immediately upon awakening and has been established over a period of at least 2 years immediately preceding, with or without medication; a specific prolonged aura accompanied by sufficient warning has been established over a period of at least 2 years immediately preceding, with or without medication; the individual previously had been free from seizure for a 6-month period and the subsequent seizure or seizures occurred as a result of a prescribed change in or removal from medication while under the supervision of a licensed physician. This waiver will only be provided upon reinstitution of previous medication; or the person previously had been free from seizure for 6 months and the subsequent seizure or seizures occurred during or concurrent with a nonrecurring transient illness, toxic ingestion, or metabolic imbalance. § 83.4(c) also requires providers who treat a person who has experienced a single seizure to also report that individual to the Department.
Substance Use
(DL-128)
(DL-128 - Click Here to Submit Online)
§ 83.5(b)(7) states that a provider can disqualify someone from driving if the provider feels the individual's use of any drug or substance, including alcohol, which is known to impair skill or functions, regardless whether the drug or substance is medically prescribed, is likely to impair their ability to safely operate a motor vehicle.
 
Condition Chapter 71 - School Bus Driver Medical Regulations
Cardiovascular
(DL-120A Cardiovascular form)

(DL-705 Cardiovascular waiver)
§ 71.3(b)(5) states that a person who has no established medical history or clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency or pacemaker insertion is qualified to drive a school bus without applying for the School Bus Driver Cardiovascular Waiver. School bus drivers that have a history of coronary artery disease, previous myocardial infarction, congenital heart defects, cardiomyopathy, pericarditis, myocarditis, chronic atrial flutter/fibrillation or valvular heart disease, and individuals who have undergone corrective surgery for congenital heart defects, coronary angioplasty, valve repair/replacement, coronary artery bypass graft surgery, or ablative surgery for paroxysmal supraventricular arrhythmias, may be qualified to drive if the individual annually meets established waiver criteria. Refer to the above link to Chapter 71 for more information. In addition, § 71.3(b)(6) states that a person who has no established medical history or clinical diagnosis of other cardiovascular disease resulting in syncope, dyspnea, loss or impairment of consciousness, collapse, or congestive cardiac failure is qualified to drive a school bus. § 71.3(b)(7) states that a person who has no established medical history or clinical diagnosis of hypertension resulting in syncope, dyspnea, loss or impairment of consciousness, collapse, or congestive cardiac failure is qualified to drive a school bus.
Cognitive Impairment
(DL-131SB)
§ 71.3(b)(15) states that a driver is qualified to drive a school bus providing they have no other condition which in the opinion of the examining physician is likely to impair the ability to drive a school bus safely.
Diabetes Mellitus
(DL-122A)
(DL-122A - Click Here to Submit Online)
§ 71.3(b)(4) states that a person who has no established medical history or clinical diagnosis of diabetes mellitus currently requiring use of insulin or other hypoglycemic medication is qualified to drive.

However, a waiver may be granted to an individual requiring the use of diabetic medications provided the individual meets all of the following:
  • There has been no incident of a severe hypoglycemic reaction or symptomatic hyperglycemia and the individual has been free from insulin reaction resulting in loss of consciousness, attention or awareness or the requirement of assistance from another person, for the preceding 12 months;
  • The driver submits to a diabetic examination every 6 months, and submits the results of the examination and the results of the Hemoglobin A1C (HbA1C) test on a form provided by the Department.The health care provider reviewing the diabetic examination shall be familiar with the person’s past diabetic history for 24 months or have access to that history and certify that the individual is under good diabetic control;
    • An individual who has had 2 consecutive HbA1C test results of greater than 8% must undergo additional diabetic examinations every 3 months. This includes the review of self-monitoring blood glucose logs.
    • Once the results of 2 consecutive HbA1C tests are 8% or less, the individual may discontinue the additional examination reporting requirements.
  • The driver submits to an annual dilated eye examination and submits the results of the examination on a form provided by the Department;
  • Individuals, upon hire to drive a school bus, shall manage their diabetes by complying with the following requirements:
    • Self-monitoring blood glucose 1 hour before driving, and at least every 4 hours while driving or while otherwise on duty, by using a portable blood glucose monitoring device with a computerized memory. If blood glucose is below 80 mg/DL or above 350 mg/DL, the individual may not drive until appropriate measures are taken and the individual retests within this acceptable range;
    • Submit the computerized glucometer results of blood glucose self-monitoring for review by the treating health care provider or a school transportation medical practitioner. The results shall also be submitted to the health care provider conducting the diabetic examination;
    • Maintaining a manual blood glucose monitoring log and submitting it, together with the glucose monitoring device’s computerized log, every 6 months to the health care provider conducting the 6-month diabetic examination;
    • Carrying a source of rapidly absorbable glucose at all times while driving a school bus.
Notwithstanding the provisions, a waiver may be granted to an individual who has recently suffered from a severe hypoglycemic reaction or symptomatic hyperglycemia as long as the individual has been free from severe hypoglycemic reactions or symptomatic hyperglycemia for the preceding 12 months and the subsequent severe hypoglycemic reaction or symptomatic hyperglycemia occurred while the individual was under the care of a treating physician, during or concurrent with a nonrecurring transient illness, toxic ingestion or metabolic imbalance. The above waiver will only be granted if the treating physician submits written certification indicating it is a temporary condition or isolated incident not likely to recur.

A reviewing health care provider finding that the individual previously qualified for a waiver is not complying with the requirements or is otherwise no longer qualified for the waiver shall promptly report these findings to the Department and the waiver will be rescinded.
Hearing Impairment
(DL-127)
§ 71.3(b)(12) states that a driver is qualified to drive a school bus providing they have no hearing loss greater than 40 decibels in the better ear, without a hearing aid, at frequencies of 500, 1,000, and 2,000 Hz. A person who is required to wear a hearing aid to meet the standards of this paragraph shall be tested by an audiologist or a licensed physician—M.D. or D.O.—who specializes in the treatment of otolaryngology. The individual who performs the test shall certify that the person has passed the test. A person who requires a hearing aid to meet the requirements of this paragraph shall also have a speech reception threshold of 40 decibels H. L. or better in the better ear with a hearing aid; achieve a score of 60% or better in a speech discrimination test of phonetically balanced words. Presented at 50 decibels H. L. + 12 decibels S/N—Average sound levels plus background noise. The tested shall use C.I.D. W-22 word lists and masking noise consisting of speech spectrum noise or white noise, which shall be presented in monaural indirect mode—45° Azimuth for left ear and 315° Azimuth for right ear; wear the aid and keep it operational at all times when driving the school bus; keep a good spare battery source on their person whenever driving the school bus; and present, at the time of the hearing test, an electroacoustic analysis test report of the hearing aid which indicates that the aid meets manufacturer’s specifications.
Loss of Attention, Awareness, or Consciousness of Unknown Etiology
(DL-129SB)
§ 71.3(b)(15) states that a driver is qualified to drive a school bus providing they have no other condition which in the opinion of the examining physician is likely to impair the ability to drive a school bus safely.
Neurological
(DL-124A)
§ 71.3(b)(15) states that a driver is qualified to drive a school bus providing they have no other condition which in the opinion of the examining physician is likely to impair the ability to drive a school bus safely.
Orthopedic 
(DL-126A)
§ 71.3(b)(2) states that a driver is qualified to drive a school bus providing they have no loss of a foot, a leg, a hand, or an arm; or has been granted a waiver by the Department after competency has been demonstrated through a driving examination administered in accordance with § 71.4(b)(2)(ii) and (iii) (relating to driver’s examination). In addition, a driver is qualified providing he/she has no impairment of a hand or finger likely to impair prehension or power grasping, or has been granted a waiver by the Department after competency has been demonstrated through a driving examination administered in accordance with § 71.4(b)(2)(ii) and (iii). In addition, § 71.3(b)(9) states that a driver is qualified to drive a school bus providing he/she has no established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease likely to impair the ability to drive a school bus safely.
Other conditions that affect safe driving
(DL-123A)
§ 71.3(b)(15) states that a driver is qualified to drive a school bus providing they have no other condition which in the opinion of the examining physician is likely to impair the ability to drive a school bus safely.
Psychiatric
(DL-104A)
§ 71.3(b)(11) states that a driver is qualified to drive a school bus providing they have no mental, emotional or psychiatric disorder whether functional or organic which may be manifested in a condition likely to impair the ability to drive a school bus safely, such as inattentiveness, despondency, aggressiveness, or lack of concern for the safety of self or others.
Respiratory Dysfunction
(DL-123A)
§ 71.3(b)(8) states that a person is qualified to drive a school bus providing they have no established medical history or clinical diagnosis of a respiratory dysfunction likely to impair the ability to drive a school bus safely.
Seizure Disorder/Epilepsy
(DL-121A)
§ 71.3(b)(10) states that a driver is qualified to drive a school bus providing they have no established medical history or clinical diagnosis of seizure disorders or another condition likely to cause loss or impairment of consciousness or loss of ability to drive a school bus safely. A waiver may be granted providing there has been no more than a single, nonrecurring episode of altered consciousness or loss of bodily control, occurring at least 2 years preceding application, which did not require treatment; or if a seizure disorder has been diagnosed, but the person has been episode-free for at least 5 years preceding application and has not required treatment for at least 5 years preceding application.
Substance Use/Abuse
(DL-128A)
§ 71.3(b)(13) states that a driver is qualified to drive a school bus providing they do not abuse alcohol or another drug or substance known to impair skill or functions which may be manifested in a condition such as inattentiveness, despondency, aggressiveness or lack of concern for the safety of self or others.
Tuberculosis
(DL-123A)
§ 71.3(b)(14) states that a driver is qualified to drive a school bus providing they do not have a type of tuberculosis in a transmittable stage and has taken the tuberculin test every 2 years as required by section 1418(b) of the Public School Code (24 P. S. § 14-1418(b)).