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Get GA DDS-270 2016-2024

REQUEST FOR DRIVER EVALUATION INSTRUCTIONS 1 Complete this form if you wish for the Department of Driver Services DDS to evaluate a driver s ability to drive safely. 2 Sign this request in the signature box provided* Anonymous reports will not be considered* You may request that your name not be revealed to the individual being reported* Confidentiality will be honored to the fullest extent possible. 3 Mail your completed request to Georgia Department of Driver Services Customer Service Licensing and Records Division 2206 East View Parkway Conyers GA 30013 The driver does not have to be cited* Please indicate evidence of the incapacity in the area below. If the driver was involved in a traffic accident attach a copy of the report. SECTION COMPLETION REQUIRED Name of Person being reported First MI Last Date of Birth or Approximate Age Driver License Number Vehicle License Plate Number if available Street Address City State Telephone Number Zip Code DRIVER CONDITION Check all appropriate boxes below. Please use the space below to provide specific dates if known about the driver s medical physical or mental condition such as name of disease or illness any medications taken etc* Medical Condition Confused/Disoriented Physical Condition Alcohol/Drug Use Describe below Mental/Emotional Condition Blackouts Seizures Fainting Spells Vision Condition Needs help with daily activities i*e* cooking dressing bathing etc* Weakness or Coordination Problems Other Difficulty Walking DRIVER BEHAVIOR Check appropriate boxes for driving problems you have observed Use space below for additional comments as needed. Does not see or react to other cars pedestrians etc* Turns in front of on coming cars Drives in wrong lane Allows car to drift in and out of lane Drives on wrong side of road Backs up or changes lanes without looking back or checking mirrors Acts violent or aggressive when driving Applies brake and gas pedals at the same time Drives too slow or stops for no reason Slow reactions that may be caused by medication or drugs Is confused by traffic Drives on sidewalk Has trouble steering braking or otherwise controlling car Makes driving mistakes while talking to passengers Gets lost or confused while driving near home Falls asleep while driving Fails to react to traffic signals other cars or pedestrians Other actions describe below Makes turns from wrong lane You may use the space below to further describe the driver s condition s or action s which led you to believe this driver should be evaluated by DDS* Describe any impairment serious physical injury or illness mental impairment or disorientation* Describe any traffic law violations whether or not a citation was issued* The following section must be completed including a signature and date in order for DDS to initiate an evaluation* Your relationship to driver check one Relative Please state exact relationship Law Enforcement Officer Physician Caregiver Vision Specialist Other Check here if you would like to have your name kept confidential* Confidentiality will be honored to the fullest extent possible.

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