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Highway Special 

Investigation Report

Medical Oversight of Noncommercial Drivers

NTSB/SIR-04/01

PB2004-917002 National Transportation Safety Board

Notation 7673A 490 LíEnfant Plaza, S.W.

Adopted November 9, 2004 Washington, D.C. 20594
National Transportation Safety Board. 2004. Medical Oversight of Noncommercial Drivers.

Special Investigation Report NTSB/SIR-04/01. Washington, DC.

Abstract: The National Transportation Safety Boardís interest in the medical oversight of noncommercial

drivers stems from its examination of six noncommercial vehicle accidents in which a driverís medical

condition played a role. The Safety Board has also investigated a substantial number of commercial

vehicle and school bus accidents involving drivers with impairing or potentially impairing medical

conditions.

As a result of its accident investigations and from its March 2003 public hearing, at which the factors that

contribute to medically related accidents were discussed, the Safety Board identified the following safety

issues:

ï Need for more data on the extent to which medical conditions contribute to the cause of

accident.

ï Need for improved awareness and training for healthcare professionals, law enforcement, and

the public regarding State medical oversight laws and practices.

ï Existence of barriers to the reporting of medically impaired drivers.

ï Lack of uniform medical assessment and oversight standards throughout the States.

ï Deficiencies in alternative transportation options for those who should not drive.

The Safety Board has issued recommendations to the U.S. Department of Transportation, the National

Highway Traffic Safety Administration, the National Committee on Uniform Traffic Laws and

Ordinances, the American Association of Motor Vehicle Administrators, the Commission on Accreditation

for Law Enforcement Agencies, the Liaison Committee on Medical Education, the American Osteopathic

Association, the Association of American Medical Colleges, and the Federation of State Medical Boards. 

The National Transportation Safety Board is an independent Federal agency dedicated to promoting aviation,

railroad, highway, marine, pipeline, and hazardous materials safety. Established in 1967, the agency is mandated by

Congress through the Independent Safety Board Act of 1974 to investigate transportation accidents, determine the

probable causes of the accidents, issue safety recommendations, study transportation safety issues, and evaluate the

safety effectiveness of government agencies involved in transportation. The Safety Board makes public its actions

and decisions through accident reports, safety studies, special investigation reports, safety recommendations, and

statistical reviews.

Recent publications are available in their entirety on the Web at <http://www.ntsb.gov>. Other information about

available publications also may be obtained from the Web site or by contacting:

National Transportation Safety Board

Public Inquiries Section, RE-51

490 LíEnfant Plaza, S.W.

Washington, D.C. 20594

(800) 877-6799 or (202) 314-6551

Safety Board publications may be purchased, by individual copy or by subscription, from the National Technical

Information Service. To purchase this publication, order report number PB2004-917002 from:

National Technical Information Service

5285 Port Royal Road

Springfield, Virginia 22161

(800) 553-6847 or (703) 605-6000
iii Special Investigation Report

Contents

Acronyms and Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Accident Narratives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Hagerstown, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Driver Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1

Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Frederick, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5

Medical Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

 Other Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Lady Lake, Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Washington County, Maryland . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

Lebanon, Pennsylvania . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Deerfield Beach, Florida . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11

Medical Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Driver Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14

Reporting Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Physician Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Emergency Medical Technicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20

Law Enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

The Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

State Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Alternative Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

Public Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Previous Safety Board Actions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Medical Oversight of Commercial Drivers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34

Over-the-Counter and Prescription Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36

Alcohol Addiction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37

Analysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40

Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

Information and Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Physicians and the Public . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

Law Enforcement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Physicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

Emergency Medical Technicians . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Reporting Accidents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

State Oversight . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50

Alternative Transportation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52
Contents iv Special Investigation Report

Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54

Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

New Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55

Previously Issued Recommendations Classified in This Report . . . . . . . . . . . . . . . . . . . . . 57

Appendixes 

A: Investigation and Public Hearing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59

B: Medically Related Safety Board Highway Investigations . . . . . . . . . . . . . . . . . 60

C: Commercial Driver Medical Oversight Recommendations . . . . . . . . . . . . . . . . 61

D: Safety Board Public Hearing Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

E: Laws of States With Mandatory Physician Reporting . . . . . . . . . . . . . . . . . . . . . 69

F: State Immunity Laws . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

G: State Oversight Procedures of Four Representative States . . . . . . . . . . . . . . . . 79

H: American Automobile Association Basic Best Practices for 

Medical Advisory/Review Boards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88

I: United We Ride Initiative . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

J: Sixteen Ranked Components From National Highway 

Traffic Safety Administration Survey . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
v Special Investigation Report

Acronyms and Abbreviations

AAA American Automobile Association

AAMC Association of American Medical Colleges 

AAMVA American Association of Motor Vehicle Administrators 

AARP American Association of Retired Persons

ADPE Area Driving Performance Evaluation

AMA American Medical Association 

AOA American Osteopathic Association 

BAC blood alcohol content

CALEA Commission on Accreditation for Law Enforcement Agencies

CCAM Coordinating Council on Access and Mobility 

CDL commercial driverís license

CFR Code of Federal Regulations

CME continuing medical education 

DMV Department of Motor Vehicles 

DOL U.S. Department of Labor

DOT U.S. Department of Transportation 

DRE drug recognition expert 

DRIVerS Driver Record Information Verification System

DWI driving while intoxicated 

ED U.S. Department of Education

EMS emergency medical service 

EMT emergency medical technician

FDA Food and Drug Administration 

FMCSA Federal Motor Carrier Safety Administration

FSMB Federation of State Medical Boards

FTA Federal Transit Administration

GAO U.S. Government Accountability Office 

HHS U.S. Department of Health and Human Services

IADLEST International Association of Directors of Law Enforcement 

Standards and Training 

LCME Liaison Committee on Medical Education 

MAB Medical Advisory Board 
Acronyms and Abbreviations vi Special Investigation Report

MMUCC Model Minimum Uniform Crash Criteria 

MVA Motor Vehicle Administration

NAEMT National Association of Emergency Medical Technicians

NCSL National Conference of State Legislatures 

NDR National Driver Register

NHTSA National Highway Traffic Safety Administration

NPRM notice of proposed rulemaking 

PennDOT Pennsylvania Department of Transportation 

SAFETEA Safe, Accountable, Flexible and Efficient Transportation Equity 

Act of 2003 

SDPE Supplemental Driver Performance Evaluation 

TRB Transportation Research Board
vii Special Investigation Report

Introduction

Of the 291 million individuals living in the United States, approximately 191

million, or 65.6 percent, are licensed to drive. Every year, about 42,000 individuals die in

traffic-related crashes. The National Highway Traffic Safety Administration (NHTSA)

estimated in 2000 that highway crashes cost U.S. society about $230.6 billion a year, with

each roadway fatality costing an average of $977,000, and each critical injury crash

costing an average of $1.1 million.1

The act of driving requires the proper orchestration of sensory/perceptual,

cognitive, and motor activities in order to be performed successfully. Certain medical

conditions can negatively affect one or more of these activities, thereby increasing the

safety risk of drivers who suffer from them. The extent of the overall impact of medically

impaired drivers is not known because data are not available on the number of licensed

drivers with particular medical conditions or (except for data on alcohol-related accidents)

on the number of accidents where a driverís medical condition was a contributory factor.

However, statistics on the number of Americans with one or more of the following

medical conditions offer some perspective on the medical oversight issues that State

licensing agencies face:2

 

ï Epilepsy: 2.5 million (180,000 new diagnosed cases each year).3

ï Diabetes: 18.2 million (1 million new cases diagnosed each year in those over

20).4

ï Sleep Disorders: 50 to 70 million.5

ï Cardiovascular Disease: 23.5 million (41.7 million additional have

hypertension).6

ï Alzheimerís Disease: 4.5 million (10 percent of those over 65 years and nearly

50 percent of those over 85 years suffer from the disease).7

1 L. Blincoe, A. Seay, E. Zaloshnja, T. Miller, E. Romano, S. Luchter, and R. Spicer, The Economic

Impact of Motor Vehicle Crashes, 2000, DOT HS 809 446 (Washington, DC: NHTSA, 2000). 

2 See the American Medical Associationís Physicianís Guide to Assessing and Counseling Older

Drivers (Chicago 2003), <http://www.ama-assn.org/go/olderdrivers>, for a more exhaustive list of medical

conditions and medications that may impair driving.

3 Epilepsy Foundation <http://www.epilepsyfoundation.org/answerplace/statistics.cfm>.

4 National Diabetes Information Clearinghouse <http://diabetes.niddk.nih.gov>.

5 U.S. Department of Health and Human Services, 2003 National Sleep Disorders Research Plan,

National Institutes of Health Publication No. 03-5209 (Washington, DC: HHS, 2003).

6 U.S. Department of Health and Human Services, Summary Health Statistics for U.S. Adults: National

Health Interview Survey, 2001, Series 10, No. 218 (Washington, DC: HHS, 2004).

7 National Institute on Aging, Progress Report on Alzheimerís Disease, 1999, NIH Publication No. 99-4664

(Bethesda, MD: National Institute on Aging, 1999).
viii Special Investigation Report

ï Arthritis: 40 million (over 7 million report limited activity due to the disease).8

ï Eye Diseases: 5.5 millionñcataracts, 2 millionñglaucoma, and 1.2 millionñ

later-stage macular degeneration.9

ï Alcoholism: 14 million (alcohol linked to 40 percent of all automobile

fatalities).10

The National Transportation Safety Boardís interest in the medical oversight of

noncommercial drivers stems from its examination of six noncommercial vehicle

accidents in which a driverís medical condition played a role. On March 23, 2002, a driver

with a history of seizure-related accidents failed to stop his vehicle at a signalized

intersection in Frederick, Maryland, resulting in a multiple vehicle collision that claimed

the lives of a father and three children. On November 3, 2002, a driver with a history of

epilepsy ran her vehicle through two intersections in Hagerstown, Maryland, and collided

with two vehicles, resulting in one fatality. Evidence indicates that both drivers were

suffering seizures at the time of the accidents. The Safety Board examined four other

medical impairment-related accidents, one involving a diabetic driver and three involving

drivers who experienced seizures. The Safety Board has also investigated a substantial

number of commercial vehicle and school bus accidents involving drivers with impairing

or potentially impairing medical conditions, such as cardiovascular disease, visual

impairment, renal disease, and sleep disorders. (See appendix B.)

In March 2003, the Safety Board held a public hearing to discuss the factors that

contribute to medically related accidents. Major topics included the:

ï Current state of knowledge regarding potentially impairing medical conditions.

ï Adequacy of procedures for reporting medically impaired drivers.

ï State licensure and oversight of drivers with high-risk medical conditions.

ï Programs to increase public awareness of State oversight laws and procedures. 

ï Rehabilitation and transportation options for medically impaired drivers.

As detailed in this report, the Safety Board learned during the course of the hearing

that the issues that encompass the medical oversight of noncommercial drivers are

complex and will require the close cooperation of Federal, State, and private organizations

to create an effective and uniform system that protects public safety while being sensitive

to the needs of individual drivers.

8 R.C. Lawrence, C.G. Helmick, F.C. Arnett, R.A. Deyo, D.T. Felson, E.H. Giannini, S.P. Heyse,

R. Hirsch, M.C. Hochberg, G.G. Hunder, M.H. Liang, S.R. Pillemer, V.D. Steen, and F. Wolfe, ìEstimates of

the Prevalence of Arthritis and Selected Musculoskeletal Disorders in the United States,î Arthritis and

Rheumatism, 41(5) (1998): 778-799.

9 University of Washington Department of Ophthalmology <http://depts.washington.edu/ophthweb/

statistics.htm>.

10 Traffic Safety Facts 2003: Alcohol, DOT HS 809 761 (Washington, DC: NHTSA, 2003).

Introduction
ix Special Investigation Report

As a result of its accident investigations and discussions stemming from the public

hearing, the Safety Board identified the following safety issues:

ï Need for more data on the extent to which medical conditions contribute to the

cause of accident.

ï Need for improved awareness and training for healthcare professionals, law

enforcement, and the public regarding State medical oversight laws and

practices.

ï Existence of barriers to the reporting of medically impaired drivers.

ï Lack of uniform medical assessment and oversight standards throughout the

States.

ï Deficiencies in alternative transportation options for those who should not

drive.

The Safety Board is making recommendations to the U.S. Department of

Transportation, the National Highway Traffic Safety Administration, the National

Committee on Uniform Traffic Laws and Ordinances, the American Association of Motor

Vehicle Administrators, the Commission on Accreditation for Law Enforcement

Agencies, the Liaison Committee on Medical Education, the American Osteopathic

Association, the Association of American Medical Colleges, and the Federation of State

Medical Boards. 

Introduction

1 Special Investigation Report

Accident Narratives

In November 2002, the National Transportation Safety Board investigated an

accident that occurred in Hagerstown, Maryland, involving a driver with a history of

epilepsy. The Safety Board subsequently identified five other accidents in which medical

incapacitation was the probable cause. Four of the five accidents involved drivers with a

history of seizures, which does not necessarily reflect the frequency with which seizurerelated accidents occurred. While studying the problems associated with licensing drivers

with a history of seizures, Safety Board investigators found that such problems were not

restricted to drivers with epilepsy. These findings prompted the Safety Board to broaden

its interest to encompass the medical oversight of all noncommercial drivers and was the

impetus for the public hearing held in March 2003. 

Hagerstown, Maryland

About 11:24 a.m. on November 3, 2002, a 1983 Chevrolet Caprice, operated by a

55-year-old driver, was heading northbound on U.S. Route 11 in Hagerstown, Maryland.

As the Chevrolet crossed through the signalized intersection of Bower Avenue, it struck the

left rear of a northbound 2000 Nissan Sentra operated by a 76-year-old driver, pushing the

Nissan off the east side of the highway. The Chevrolet continued northbound

approximately 571 feet, where, at the signalized intersection of Massey Boulevard, it struck

the rear of a northbound 1993 Pontiac Grand Prix operated by an 81-year-old driver. The

Chevrolet engaged the Pontiac, and both vehicles continued northbound on Route 11

approximately 349 feet, at which point the Pontiac struck a wooden utility pole on the east

shoulder of the roadway. The Chevrolet continued northbound for another 230 feet before it

came to final rest on the east roadway shoulder, against a vertical curbing. The Pontiac

driver sustained fatal injuries, the Nissan driver sustained minor injuries, and the driver of

the Chevrolet was uninjured. The Chevrolet driver stated to emergency medical service

(EMS) personnel after the accident that she had a history of seizures. (See figures 1 and 2.) 

Driver Records

Drivers are licensed by their State of residence and must meet their Stateís medical

requirement before licensure. At the time of the accident, the Chevrolet driver possessed a

valid Class C Pennsylvania driverís license with no endorsements or restrictions. Her

Pennsylvania driving history showed no violations, medical actions,11 or accidents. A check

11 In Pennsylvania, the Driver Safety Division can take action against drivers with specific medical

conditions. 
Accident Narratives 2 Special Investigation Report

of the National Driver Register12 (NDR) revealed no record of suspension or revocation.

Automobile insurance records, obtained via subpoena from the Chevrolet driverís

automobile insurance company, showed no claims made against the policy prior to this

accident.13

12 The National Driver Register is a central repository of information on individuals whose privilege to

drive has been revoked, suspended, canceled, or denied or who have been convicted of serious traffic-related

offenses. The records maintained at the NDR consist of identification information including name, date of

birth, gender, driver license number, and reporting State. States normally check the NDR prior to granting a

new license to an individual. The NDR does not contain information on medical impairment, nor does it

point to such information unless it was the cause of the license revocation, cancellation, or suspension. 

Figure 1. Pontiac Grand Prix at final rest.

13 The driver had been a policy holder with this automobile insurance company since 1982.
Accident Narratives 3 Special Investigation Report

Medical Records

Information on the Chevrolet driverís epilepsy14 was gathered through a review of

her medical records, which were obtained via subpoena from her neurologist, previous

primary care physician, and current primary care physician. 

Physicianís records from October 1987 indicate that the Chevrolet driver noted a

history of major motor seizures15 as a child. Those records indicate that she noted no

seizures from her teenage years until her mid-thirties and indicated that her seizures

returned in November 1984, when she lost consciousness in an unwitnessed event. The

Figure 2. Schematic of Hagerstown accident.

14 A brain disorder in which nerve cells in the brain sometimes signal abnormally, causing unusual

sensations, emotions, and behavior, or sometimes convulsions, muscle spasms, and loss of consciousness. 

15 Also known as grand mal or tonic-clonic seizures, this type of seizure is typified by symptoms that

include stiffening of the body and repeated jerks of the arms and/or legs as well as loss of consciousness.

U.S. Route 11

Area of 2nd collision

Wooden utility pole

Vehicle 1

Chevrolet Caprice

Vehicle 3

Pontiac Grand Prix

Area of 1st collision

Vehicle 2

Nissan Sentra

Massey Boulevard

Bower Avenue
Accident Narratives 4 Special Investigation Report

physicianís records note that she made a visit in October 1987 for a ìform to be filled out

for driving license.î The driver was a resident of Maryland at the time of that visit. The

nature of this form was not specified in her medical records.

The driver moved from Maryland to Pennsylvania in 1992, but continued to see a

physician in Hagerstown, Maryland. In January 1993, her family physicianís records

indicate that the Chevrolet driver complained of an occasional ìtinglingî sensation that

she associated previously with the arrival of a seizure event.16 In July 1995, those records

indicate episodes in the evenings when she felt very lethargic and unable to respond to her

husband when he spoke to her. She did not report loss of consciousness and indicated that

she was able to raise her hand to show her husband how she felt.

In May 1996, the Chevrolet driver reported to her family physician that she

experienced seizures ìevery few days,î but reported that they had ìdecreased to about

once per week or 10 daysî since increasing the dosage of her seizure medication,

phenytoin. The Chevrolet driver was referred to a neurologist, who saw her in June 1996.

According to the neurologistís records, the driver reported getting a ìweird feelingî across

her body immediately before a seizure. Her husband reported that during a seizure, the

driver ìwould get a strange look on her face.î The Chevrolet driver stated that she ìwould

lose contact with the environment for a period of a few seconds.î After the seizure, she

would feel mildly confused, but would otherwise feel fine, with no postseizure headache,

drowsiness, nausea, or vomiting.

The Chevrolet driver continued to experience seizures until the time of the

accident. In January 2001, her physician counseled her not to drive ìthis weekî and to see

a neurologist regarding the abnormal sensations she was experiencing on the left side of

her head. In June 2001, physician records document the Chevrolet driver calling to

indicate that she had experienced two seizures within a span of 11⁄2 weeks, and that she had

felt no warning prior to their onset. The neurologistís records from January 2002 indicated

that the Chevrolet driver was still having seizures and that they were ìworse than before.î

He added a prescription for the medication gabapentin17 for the first time, and

recommended that she notify the Motor Vehicle Administration (MVA)18 of her condition

and not drive for 3 months. The family physicianís records note the January 2002

neurologistís recommendation that the Chevrolet driver not operate a motor vehicle. The

neurologistís records from February 2002 indicated that the Chevrolet driver was again

instructed not to drive, this time for 6 months, and to notify the MVA of her condition. No

evidence was found to indicate that the Chevrolet driver or her physicians ever notified the

Pennsylvania or Maryland licensing authority of her condition.

16 Many individuals with epilepsy report feeling a bodily sensation immediately prior to, or up to

several hours before, the onset of some seizures. This forewarning is generally referred to as an ìaura.î

Auras vary among individuals. 

17 Also known by the trade name Neurontin, this is an anticonvulsive used to treat seizures and

shingles.

18 By this time, the driver was a resident of Pennsylvania, which refers to its licensing agency as the

Department of Motor Vehicles.
Accident Narratives 5 Special Investigation Report

In March 2002, the Chevrolet driver again reported to her family physician that she

had experienced a seizure that lasted half a minute. In June 2002, after she reported having

a seizure at work, her neurologist instructed her not to operate a vehicle for 6 months and

to notify the MVA. Her neurologist described her disorder as ìfairly controlledî since the

addition of the gabapentin. Neurologist records from August 2002 indicate that the

Chevrolet driverís seizures were ìwell under controlî under the medications prescribed

(gabapentin and phenytoin), noting that she had not had a seizure since June. It also

indicated that the Chevrolet driver recently lost her job and would soon be without health

insurance coverage.

In October 2002, 5 days before the accident, the Chevrolet driver indicated to her

neurologist that she had experienced three seizures in the previous week, as well as

episodes of falling not associated with a loss of consciousness. She told the neurologist

further that she had stopped taking gabapentin during the 2 weeks prior to the accident due

to the expense and her lack of insurance coverage. 

Frederick, Maryland

On March 23, 2002, a 1997 Oldsmobile Cutlass driven by a 34-year-old driver was

southbound on Butterfly Lane in Frederick County, Maryland. As the Oldsmobile

approached traffic at a signalized intersection, the driver failed to stop and struck the rear

of a 1994 Hyundai occupied by a 39-year-old driver and three passengers between the

ages of 8 and 10. The Hyundai was pushed forward, causing a series of rear-end collisions

involving a total of six vehicles. All four Hyundai occupants were fatally injured. (See

figure 3.) 

A preliminary police investigation revealed that the driver of the Oldsmobile

suffered from epilepsy, had received a vagal nerve implant,19 and was taking prescription

medication to control seizures. 

Driver Records

A review of the Oldsmobile driverís records revealed no moving violations, no

alcohol-related offenses, and no previous accidents. These records indicated that the driver

had no restrictions concerning physical or mental disabilities. However, the Oldsmobile

driverís records stated that the Maryland MVA Medical Advisory Board (MAB) had

previously suspended the Oldsmobile driverís operating privileges on February 12, 2001.

The reason for this suspension did not appear in the driverís records. The Safety Board

determined through further investigation that the suspension was apparently the result of a

November 12, 2000, motor vehicle accident in which the driver suffered a seizure while

driving and subsequently struck an occupied residence. The Oldsmobile driver was mailed

19 Vagus nerve stimulation is a type of treatment in which short bursts of electrical energy are directed

into the brain via the vagus nerve, a large nerve running from the brain through the neck and chest. The

patient may also initiate a burst to help prevent an anticipated seizure. This treatment is used when

medications fail to stop seizures and when surgery is not a viable alternative.
Accident Narratives 6 Special Investigation Report

a medical package, which instructed him to undergo an evaluation by a physician and to

complete a functional capacity test.20 The suspension was withdrawn on April 20, 2001,

after the MAB received a report from the Oldsmobile driverís neurologist stating that the

driver was physically and mentally capable of safely operating a motor vehicle. The

neurologist also noted that the Oldsmobile driver had been seizure-free since the

November 12, 2000, accident. No record was found to indicate that the Oldsmobile driver

ever underwent a functional capacity test.

After the suspension, the driver was advised that he would have to submit a ìloss

of consciousness affidavitî every 3 months for a year, and a followup report from his

physician after 1 year. The Oldsmobile driver sent the MAB an affidavit in June 2001, in

which he mentioned his medication dosage and his vagal nerve implant. The Oldsmobile

driver left blank a field that inquired about the date of his last seizure episode. No

indication exists that the MAB followed up on either the Oldsmobile driverís vagal nerve

implant or on the missing date. 

The Oldsmobile driver voluntarily surrendered his license to the MVA on

October 11, 2001, shortly after his next affidavit would have been required. During a

postaccident interview, the Oldsmobile driver indicated to Safety Board investigators that

he surrendered his license because he did not think that he was safe to drive. Further

investigation revealed that the Oldsmobile driver was involved in another accident on

20 A battery of physical and cognitive tests used to assist in determining an individualís ability to safely

operate a motor vehicle.

Figure 3. Hyundai at final rest.
Accident Narratives 7 Special Investigation Report

August 28, 2001, a month before surrendering his license. He requested, and was reissued,

a duplicate Maryland operatorís license on February 16, 2002. His file contained no other

entries before the Frederick, Maryland, accident.

Law enforcement and Safety Board investigators were able to gather further

information about the Oldsmobile driverís accident history by reviewing his insurance

records and his vehicleís history report.21 (See table 1 for a chronology of the Oldsmobile

driverís activities after 1995.) According to the Manager of the Driver Wellness and

Safety Division of the Maryland MVA, accident information is not posted to a driverís

driving record unless an official charge or summons is issued by investigating police.

Although a driver may be at fault for an accident, this information is not available to the

MVA unless police charge the driver. 

Medical Records

Medical information on the Oldsmobile driver was obtained via subpoena from his

neurologist and family physician. Medical records indicated that the Oldsmobile driver

had a history of seizures since childhood, consisting of ìstaring spells,î often with loss of

awareness, with occasional involvement of the left leg, and usually followed by a period

of sleepiness and some visual field defects that resolved over time. The seizures occurred

as frequently as several times a day and were only intermittently controlled with

medication. 

His neurologistís medical records also indicated that the Oldsmobile driver was

routinely ìnoncompliantî with his neurologistís instructions, did not take medication as

scheduled, cancelled or did not show for appointments, and was frequently unaware of his

own seizures. The records also indicated that the neurologist questioned the Oldsmobile

driver about his driving habits on several occasions. On November 17, 2000, after the

Oldsmobile driver mentioned that he crashed into a house following a seizure, the

neurologist told the Oldsmobile driver that ìhe should not drive for at least the next 3

months, and if he continues to be noncompliant, should not be driving at all.î

Nonetheless, after the Oldsmobile driverís license was suspended in February 2001, his

neurologist indicated to the MAB on February 26, 2001, that the Oldsmobile driver was

ìreliable in taking medications,î that the ìpatientís seizures/medical condition is

controlled,î and that the driver ìis physically/mentally capable of safely operating a motor

vehicle at this time.î

21 The Oldsmobile vehicle history was obtained through <www.carfax.com>.
Accident Narratives 8 Special Investigation Report

Table 1. Driving history of the Oldsmobile driver involved in the Frederick, Maryland, accident. 

(Items in bold are those not included in the Oldsmobile driver's official driving records.)

Other Accidents

Lady Lake, Florida

At about 7:45 p.m. on December 11, 2002, a 54-year-old driver licensed in Georgia

and operating a 2000 Jeep Cherokee was traveling westbound on Main Street in Lady

Lake, Florida. According to the police, as the Jeep driver crossed the intersection of Paige

Place, he suffered a seizure, lost control of his vehicle, and struck a 74-year-old pedestrian

who was helping to direct traffic in the intersection as part of an outdoor festival. The Jeep

then left the roadway and struck several more pedestrians. Two pedestrians were killed,

and 13 others sustained various injuries; the Jeep driver was uninjured. (See figure 4.)

Date Event

Before 1995 No information available

December 21, 1995 Name change

January 28, 1996 Involved in property damage accident

November 5, 1997 Involved in bodily injury accident

February 5, 1998 Involved in property damage accident 

November 12, 2000 Involved in an accident in which his vehicle struck

 an occupied residence

November 13, 2000 Frederick police requested a reexamination for medical condition

February 12, 2001 Suspended by MVA

April 20, 2001 Suspension withdrawn by MVA

August 28, 2001 Involved in property damage accident

October 11, 2001 Driverís license voluntarily turned in to MVA

February 16, 2002 Reapplied for and obtained driverís license

February 16, 2002 Address change

March 23, 2002 Involved in fatal accident involving a seizure

March 26, 2002 Investigation division requested to secure driverís license

March 27, 2002 Driver privilege suspended by MVA

March 28, 2002 Driverís license received and destroyed

April 2, 2002 Police request reexamination 

March 2, 2003 Driver sentenced to 6 years in prison due to deaths resulting from March 

2002 accident

Driving privileges suspended permanently
Accident Narratives 9 Special Investigation Report

The Jeep driver told Safety Board investigators that he began having seizures in

his early teens. According to his medical records, he told his physician that he had

experienced about eight to nine grand mal seizures in his lifetime, and partial seizures22

about once or twice a year. In January 1999, he suffered a grand mal seizure and fell down

a flight of steps, resulting in head injuries that led to speaking difficulty and mild rightsided weakness. Medical records from February 1999 indicate that the physician and the

Jeep driver discussed Georgiaís law restricting driving for 1 year after a seizure.23 Medical

records from January 2002 indicated that although the Jeep driver believed that he had not

been experiencing seizures, his wife reported that he had about one seizure every 2

months. The physicianís records indicated that he reminded the driver about the Georgia

driving restrictions. 

Records from February 2002 indicate that the Jeep driver was experiencing

memory difficulties that were likely due to the fall he suffered in 1999. The Jeep driver

had brain surgery in April 2002 to relieve a subdural hematoma24 resulting from the fall.

Figure 4. Jeep at final rest.

22 Seizures that affect a limited area of one cerebral hemisphere. 

23 Georgia State Code Section 40-5-35 was modified in February 2000 to reduce the required seizurefree period from 1 year to 6 months. 

24 Bleeding into the space between the dura (the brain cover) and the brain itself. If the hematoma puts

increased pressure on the brain, neurological abnormalities, such as slurred speech, impaired mobility, and

dizziness may result. Untreated, this condition could lead to coma and even death.
Accident Narratives 10 Special Investigation Report

Medical records from August 2002 indicate that Jeep driver continued to show moderate

to severe problems with verbal and visual memory despite the surgery. In addition, the

records noted that his wife reported that the driver was also ìhaving significant difficulty

doing simple tasks, and requires much structure and instruction, as though he is having to

relearn things.î 

Medical records dated 6 days after the crash note that the Jeep driver had been

seizure-free for over a year before the events leading to the accident and that he had been

taking his medication as prescribed. It also indicated that he experienced symptoms of a

partial complex seizure immediately before losing control of the vehicle. 

Washington County, Maryland

On June 7, 2001, a 70-year old driver, licensed in Virginia, was driving a 1997

Ford Windstar van westbound on Interstate 70, Washington County, Maryland. The

weather was clear, the roadway dry, and the visibility was good. The Ford approached a

right-hand curve, failed to negotiate it, and ran off the roadway, into the median. The Ford

continued through the median and encroached into the eastbound travel lanes, where it

struck a 1992 Chevrolet Lumina, a 2001 Volvo tractor-semitrailer, and a 1992 Chevrolet

Beretta. The operator of the Lumina suffered fatal injuries; the two occupants of the Ford

suffered serious injuries. The operator of the tractor-semitrailer and the Beretta suffered

minor injuries. (See figure 5.)

After the crash, the investigating trooper interviewed the passenger in the Ford,

who stated the driver had suffered a brain injury in 1996 and had experienced blackouts

since then, with the last blackout occurring over a year before the accident. The Fordís

passenger also told the trooper that the driver was currently taking medication known to

Figure 5. Chevrolet Lumina and Volvo tractor-semitrailer at final rest.
Accident Narratives 11 Special Investigation Report

treat seizures. A check of the Ford driverís Virginia operatorís license did not indicate any

previous history of accidents, suspensions, or medical restrictions. 

Lebanon, Pennsylvania

On October 15, 2003, a 1995 Chevrolet Astro was traveling eastbound on East

Lehman Avenue in Lebanon, Pennsylvania. The 49-year-old driver was the sole occupant

of the Chevrolet. The weather was clear and the roadway was dry. According to witnesses,

the Chevrolet made a right turn into the parking lot of the Turkey Hill convenience store

located at 716 East Lehman Avenue. After the turn, the Chevrolet continued straight

through the lot and struck the front window of the store. The Chevrolet drove into the

building, struck two persons standing near the checkout counter, continued through the

store, struck a third person standing by the soda counter, and came to rest near the rear

wall of the store. During the accident sequence, three additional persons in the store were

struck by flying debris. The accident resulted in serious injuries to one individual,

moderate injuries to another, and minor injuries to the driver and four others.

A witness outside the store told police the brake lights of the Chevrolet never came

on. Another witness, a store employee inside the store at the time of the accident, told

police that the Chevrolet driver exited the vehicle after the accident, looking ìhysterical,î

and then appeared to suffer a seizure, falling to the ground. In an interview with police

after the accident, the Chevrolet driver stated that she had not been feeling well and had

decided to pull into the store to get something to drink. She stated that she could not

remember anything from that point on, including how she got to the hospital. The

postaccident investigation by Lebanon police revealed that the Chevrolet driver had

a history of seizures but had been cleared to drive following brain surgery about a year

before the accident.

Deerfield Beach, Florida 

On January 31, 2003, a 61-year-old driver lost control of her late-model Lincoln

Continental, traveled approximately 25 feet from the intersection of South Federal

Highway near Deerfield Beach, Florida, and crashed into a Winn-Dixie food store. Two

occupants of the store were injured and transported to a local hospital. According to

police, after the accident, the Lincoln driver stated that she had been diagnosed with

diabetes and may have blacked out before the accident. Her driving record indicated no

previously reported crashes in the 3 years before this accident. At the time of the accident,

the roadway was dry, the skies were clear, and the visibility was good.
12 Special Investigation Report

Medical Oversight

In its public hearing on March 18 and 19, 2003, the Safety Board examined the

state of noncommercial driver medical oversight (appendix D).25 Healthcare experts from

academia, advocacy organizations, and Federal and State governments participated in this

hearing, which included the following major topics: (1) current knowledge regarding

potentially impairing medical conditions, (2) identification and reporting of medically

high-risk drivers, (3) procedures for assessing the driving fitness of medically high-risk

drivers, (4) State licensure and oversight of noncommercial drivers with high-risk medical

conditions, (5) programs to increase public awareness of State oversight laws and

procedures, and (6) rehabilitation and transportation options for medically high-risk

drivers. 

The following sections summarize the issues pertaining to the medical oversight of

noncommercial drivers and derive primarily from discussions held during the Safety

Boardís hearing. 

Research

Medical conditions such as epilepsy have the potential to adversely affect a

driverís ability to operate a motor vehicle, as the accident investigations described earlier

indicate. Research has identified several other conditions associated with an increased risk

of motor vehicle accidents: visual impairments, cardiovascular diseases, metabolic

diseases, psychiatric diseases, cerebrovascular diseases, renal diseases, respiratory

diseases, and musculoskeletal diseases.26 The role of medical impairment in accident

causation is an issue of concern that may become more prominent due to the growing

number of senior27 and obese28 citizens. 

25 Information on this hearing, including the full transcript, is available at <http://www.ntsb.gov/events/

2003/med_noncomm/default.htm>. 

26 B.M. Dobbs, Medical Conditions and Driving: Current Knowledge, contract #DTNH22-94-G-05297.

Submitted to the Association for the Advancement of Automotive Medicine under contract with NHTSA

(2002).

27 Aging has been associated with visual impairments, cardiovascular diseases, metabolic diseases,

psychiatric diseases, cerebrovascular diseases, respiratory diseases, pulmonary diseases, and

musculoskeletal diseases. See Physicianís Guide to Assessing and Counseling Older Drivers,

<http://www.ama-assn.org/go/olderdrivers>.

28 In the United States, 61 percent of adults are overweight or obese. The Centers for Disease Control

and Prevention lists several diseases that are associated with obesity, including Type 2 diabetes, stroke,

coronary heart disease, osteoarthritis, obstructive sleep apnea and respiratory problems, and psychological

disorders like depression (<http://www.cdc.gov/nccdphp/dnpa/obesity>).
Medical Oversight 13 Special Investigation Report

Researchers have attempted to estimate the increased crash risk for medically

high-risk drivers.29, 30, 31 A comprehensive longitudinal study of restricted and unrestricted

drivers with high-risk medical conditions32 found that medically high-risk drivers

generally had a higher rate of at-fault crashes when compared with matched controls, but

that the relative risk differed greatly depending on the condition (table 2). For example,

unrestricted drivers33 with cardiovascular disease had an at-fault accident risk equal to that

of drivers in a comparison group, whereas unrestricted drivers with learning, memory, or

communication deficits (such as Alzheimerís disease and mental retardation) were 3.32

times more likely to cause an accident than drivers in a comparison group. The authors

recommended that licensing authorities place greater consideration on the functional

ability categories that show a higher risk of crashes (such as learning and neurological and

episodic conditions) or that comprise a greater number of drivers.

Table 2. Relative risk for at-fault crashes for medically high-risk drivers as compared with 

a matched comparison group, Utah 1992-1996.34

29 T.D. Koepsell, M.E. Wolf, L. McCloskey, D.M. Buchner, D. Louie, E.H. Wagner, and R.S. Thompson,

ìMedical Conditions and Motor Vehicle Collision Injuries in Older Adults,î Journal of the American

Geriatric Society, 42(7) (1994): pp. 695-700.

30 G. McGwin, R.V. Sims, L. Pulley, and J.M. Roseman, ìRelations Among Chronic Medical

Conditions, Medications, and Automobile Crashes in the Elderly: A Population-Based Case-Control Study,î

American Journal of Epidemiology, 152(5) (2000): 424-31.

31 C. Owsley, G. McGwin, and K. Ball, ìVision Impairment, Eye Disease, and Injurious Motor Vehicle

Crashes in the Elderly,î Ophthalmic Epidemiology, 5(2) (1998), 101-13.

32 E. Diller, L. Cook, E. Leonard, J. Reading, J.M. Dean, and D. Vernon, Evaluating Drivers Licensed

With Medical Conditions in Utah, 1992-1996, DOT-HS-809-023 (Washington, DC: NHTSA, 1999).

33 Drivers whose driving privileges are not limited by the State licensing agency to a specified time,

place, or method of operation. 

Functional ability category Licensing statusa

a.Unrestricted drivers have full license privileges, while restricted drivers have speed, area, or time-of-day limitations.

Unrestricted Restricted

Diabetes and other metabolic conditions 1.46 1.77

Cardiovascular 1.00 1.54

Pulmonary 1.26 1.60

Neurological 2.20 1.40

Epilepsy and other episodic conditions 2.02 2.39

Learning, memory, and communication 3.32 -

Psychiatric or emotional conditions 1.85 2.89

Alcohol and other drugs 2.22 5.75

Visual acuity 1.52 1.56

Musculoskeletal abnormality or chronic medical debility 1.84 11.29

Functional motor impairment 1.71 -

34 Medically high-risk drivers and the comparison group were matched on age, gender, and location of

residence. The numbers indicate the relative risk for at-fault crashes for medically high-risk drivers when

compared with the matched comparison group. For example, a relative risk of ì2.00î means that the

medically high-risk group is twice as likely to be involved in an at-fault crash as the comparison group.
Medical Oversight 14 Special Investigation Report

Driver Assessment

During the Safety Boardís hearing on medical oversight of noncommercial drivers,

several witnesses testified that not enough was known about the effects of certain medical

conditions on driving ability. According to Dr. Allan Krumholz, Professor of Neurology and

Director of the Maryland Epilepsy Center, many studies suffer from methodological

limitations, such as small sample size, lack of uniform criteria, lack of exposure data, and the

absence of evidence that the crashes were a direct result of driver medical conditions.35 Dr.

Bonnie Dobbs, Associate Director of the University of Alberta Rehabilitation Research

Centre in Alberta, Canada, stated that because medical conditions may result in various levels

of impairment among individuals, individualized assessment based on functional ability was

the fairest and most accurate screening technique.36 According to Dr. Dobbs, functional

impairments associated with driving can generally be classified as chronic or acute, and this

classification has important implications for assessment. Acute conditions are characterized

by periods of impairment that are sporadic and often unpredictable, such as epilepsy and

cardiovascular disease. Making fitness-to-drive decisions for drivers with acute conditions

cannot be based solely on direct measurement because of the nature of such illnesses. Driver

screening for those with acute conditions instead must be based on clinical judgments of

individual cases and on a policy of acceptable risk for society. Conversely, chronic conditions

are characterized by impairments that are often stable or that show fairly predictable

functional declines, such as visual and musculoskeletal conditions. These characteristics

allow fitness-to-drive decisions to be based on performance rather than estimates of risk. 

In assessing acute conditions, licensing agencies must determine an acceptable

level of risk. According to Dr. Krumholz, ìthe issue is really how one can predict who is

likely to have a problem while driving.î He related the results of a study he co-authored,

which found that the best predictors of crash risk among drivers with epilepsy were the

length of seizure-free intervals, the presence of reliable auras, the number of previous

seizure-related accidents, and changes in antiepileptic drugs.37 He believed that many of

these factors are oftentimes not considered adequately in the licensing regulations. Dr.

Krumholz noted that advances in the knowledge and treatment of diseases such as

epilepsy have allowed licensing agencies to lower the accident risks associated with them.

Before 1949, no individual diagnosed with epilepsy was allowed to drive in the United

States. However, this restriction was changed with the understanding that epilepsy is a

condition that can be controlled and predicted in some individuals. According to the Centers

35 Testimony of Dr. Allan Krumholz, Professor of Neurology and Director of the Maryland Epilepsy

Center, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003.

36 Testimony of Dr. Bonnie Dobbs, NTSB hearing, Medical Oversight of Noncommercial Drivers,

March 18-19, 2003.

37 G.L. Krauss, A. Krumholz, R.C. Carter, G. Li, and P. Kaplan. ìRisk Factors for Seizure-Related

Motor Vehicle Crashes in Patients with Epilepsy,î Neurology, 52(7) (1999): 1324-9.
Medical Oversight 15 Special Investigation Report

for Disease Control and Prevention, treatment can control seizures for 75 percent of

people with epilepsy.38 Dr. Krumholz stated, ìIn the United States today, just about every

State in the United States permits people with controlled seizures to drive.î39 

In assessing chronic conditions, licensing agencies must find the right technique to

measure performance related to driving, determine a threshold that can be used to screen

drivers, and follow up periodically to gauge changes in performance. In assessing

dementia, Dr. Richard Marottoli, Director of the Geriatrics and Extended Care section at

the Connecticut Veterans Administration, testified that a variety of tests have been used to

measure cognitive function. According to Dr. Marottoli, general assessment procedures,

such as the mini mental state exam,40 are frequently used, but they tend to have a relatively

low association with actual driving performance. Tools that measure specific functions,

such as those that measure visual spatial ability, require training to administer and are not

often available to licensing agencies, but seem to have more validity in terms of measuring

aspects of driving fitness. However, these tests can only raise oneís awareness that a driver

with a medical condition might be at increased risk for an accident. They lack the validity

of an on-the-road assessment.41 

Some high-risk medical conditions, such as Parkinsonís and Alzheimerís disease,

change over time, necessitating regular followups.42 Studies show that drivers over 65 with

degenerative medical conditions do self-regulate to a limited extent, but that many continue

to drive despite poor health.43 A survey of 1,470 adults over 65 years old, found seven

factors of significance in predicting driving cessation: age, female gender, macular

degeneration, stroke, hospitalization in the past year, eye problems caused by general

health, and Parkinsonís disease.44 Another survey of 402 visually impaired drivers between

38 See <http://www.cdc.gov/nccdphp/epilepsy/seizures.htm>.

39 Testimony of Dr. Allan Krumholz, NTSB hearing, Medical Oversight of Noncommercial Drivers,

March 18-19, 2003. According to the Epilepsy Foundation, 41 States and the District of Columbia allow

those who have been seizure free for a specified amount of time to drive. Nine states do not specify a

seizure-free period and rely on the driverís physician or the State Medical Advisory Board to determine

driving fitness and licensure.

40 A short series of simple evaluations requiring no special tools or training that are commonly

conducted in clinical practice.

41 Testimony of Dr. Richard Marottoli, Director of the Geriatrics and Extended Care section at the

Connecticut Veterans Administration and Associate Professor of Medicine at the Yale University School of

Medicine, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003.

42 Testimony of Dr. Dana Clarke, Chairman of the Utah Medical Advisory Board and Director of the

University of Utah Diabetes Center, NTSB hearing, Medical Oversight of Noncommercial Drivers,

March 18-19, 2003.

43 A. Dobbs and B. Dobbs, The Unsafe Older Driver: Identification, Assessment and Minimizing the

Negative Consequences of Loss of Driving Privileges, Continuing Education Seminar sponsored by the

Canadian Psychological Association and the American Psychological Association (2003). 

44 R. Stewart, M. Moore, R. Marks, F. May, and others. ìDriving Cessation in the Elderly: An Analysis

of Symptoms, Diseases, and Medications, Journal of Geriatric Drug Therapy, 8(2) (1993): 45-60.
Medical Oversight 16 Special Investigation Report

the ages of 60 and 91, reported that although 80 percent of the sample acknowledged that

avoiding certain driving situations (for example, left turns, interstate highways) would

help decrease their risk of crashing, 75 percent reported rarely avoiding such situations.45 

A study of patients with Alzheimerís disease46 found that although the patients

tended to restrict their driving habits, many continued to drive despite their caregiversí

perception that they should discontinue driving altogether. The authors noted that attention

deficits were significantly associated with an absence of self-imposed driving restrictions.

Witnesses at the Safety Boardís hearing favored an active role by physicians and close

associates in determining the driving fitness of a medically high-risk individual. 

Every State has laws that regulate the driving privileges of medically high-risk

drivers. Many place license restrictions on these drivers in an attempt to lessen the risk to

all road users while granting the medically high-risk drivers some mobility. 47

Disagreement currently exists among experts and in the literature regarding the merits of

restricted licenses. The data in table 248 suggest that drivers on restricted licenses still

present a hazard to the motoring public. Another study49 found that at-fault crashes

decreased almost 13 percent among Saskatchewan drivers with high-risk medical

conditions after restrictions had been imposed on them. Although restricted drivers in this

study did have a slightly higher incidence of crashes than unrestricted drivers (incident

ratio = 1.13), the authors noted that this crash rate was still lower than that for male and

urban drivers (incident ratio = 2.01). Yet another study50 found that the availability of a

restricted license option for their patients positively influenced the decision of

Saskatchewan, Canada, physicians to report those who were perceived as unfit to drive. 

During the Safety Boardís hearing, Dr. Dobbs maintained that further research into

the applicability or the appropriateness of restricted licenses was required. She related an

example in the dementia literature that suggested that individuals be restricted to within 5

miles of home and stated that, ìif an individual is cognitively impaired to the extent that

theyíre unsafe to drive, theyíre unsafe to drive 5 miles or 20 miles or a hundred miles

within an area.î Other witnesses advocated licensing restrictions over revocation, with

Dr. Krumholz noting evidence that harsher restrictions on European drivers with medical

impairments resulted in reduced compliance with the regulations. He added that harsher

rules might discourage drivers from disclosing their disabilities to physicians and licensing

authorities, which could actually result in an increased risk to the public. Dr. Krumholz

45 B. Stalvey and C. Owsley, ìSelf-Perceptions and Current Practices of High-Risk Older Drivers:

Implications for Driver Safety Interventions,î Journal of Health Psychology, 5(4) (2000): 441-456.

46 V. Cotrell and K. Wild, ìLongitudinal Study of Self-Imposed Driving Restrictions and Deficit

Awareness in Patients with Alzheimer Disease,î Alzheimer Disease and Associated Disorders, 13(3) (1999):

151-6.

47 K.H. Lococo, Summary of Medical Advisory Board Practices in the United States, prepared for the

National Highway Traffic Safety Administration by Transanalytics, contract #DTNH22-02-P-0511 (2003).

48 Diller, Evaluating Drivers Licensed With Medical Conditions in Utah (1999).

49 S.C. Marshall, R. Spasoff, R. Nair, and C. Van Walraven, ìRestricted Driver Licensing for Medical

Impairments: Does It Work?î Canadian Medical Association Journal, 167(7) (2003): 747-51.

50 S.C. Marshall and N. Gilbert, ìSaskatchewan Physiciansí Attitudes and Knowledge Regarding

Assessment of Medical Fitness-to-Drive,î Canadian Medical Association Journal, 161(6) (1999): 687-8.
Medical Oversight 17 Special Investigation Report

concluded by stating that, ìit seems kind of counterintuitive, but making rules less severe,

less restrictive, but still reasonable, I think, has the potential to increase public safety for

many people when you look at people driving with disabilities.î

Reporting Medical Conditions

Physician Reporting 

During the Safety Boardís hearing on medical oversight of noncommercial drivers,

three issues were discussed as affecting the probability that physicians will report patients

with a high-risk medical condition to State licensing authorities: knowledge of State

reporting laws, the existence of mandatory reporting laws, and liability concerns.

Knowledge of Reporting Laws. A 1997 study51 found that although personal

physicians are the primary source of information about driving restrictions for patients

with neurological impairments, many are unaware of relevant State laws. A 2000 study 52

found that over 28 percent of geriatricians53 in the United States were unaware of the

procedures for reporting drivers with potentially unsafe degrees of dementia. In

California, where physicians are required to report drivers having moderate to severe

dementia, about 6 percent of geriatricians did not know how to report drivers with

dementia.

Dr. Claire Wang, medical advisor to the American Medical Association (AMA)

Older Drivers Project, testified during the Safety Boardís hearing54 that many of the

670,000 physicians involved with patient care are not familiar with their own Stateís

reporting policies and procedures. Dr. Wang added that the level of knowledge can vary

greatly between States, between urban and rural areas, and between areas of medical

specialization. 

Dr. Wang believed that medical schools could do more to inform students about

the medical and legal aspects of patient driving safety. These medical aspects include the

awareness that certain medical conditions and medications can impair driving safety, and

the knowledge of how to counsel patients in those situations and on driving cessation. The

legal aspects include knowing that reporting laws and procedures exist for each State.

Dr. Wang believed that most physicians learn about their Stateís reporting laws through

word of mouth. 

51 K.K. Selmo, D.S. Asp, and D.C. Anderson, ìSeizures and Spells: Physician Awareness of Minnesota

Driving Laws,î Minnesota Medicine, 80(5) (1997): 42-6.

52 G. Cable, M. Reisner, S. Gerges, and V. Thirumavalavan, ìKnowledge, Attitudes, and Practices of

Geriatricians Regarding Patients with Dementia Who Are Potentially Dangerous Automobile Drivers: A

National Survey,î Journal of the American Geriatric Society, 48(1) (2000): 100-2.

53 Geriatricians are physicians who specialize in treating diseases associated with aging.

54 Testimony of Dr. Claire Wang, Medical Advisor to the American Medical Associationís Older

Drivers Project, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003.
Medical Oversight 18 Special Investigation Report

Several States have published guidebooks and held training sessions to boost

physician awareness of State reporting laws. For example, North Carolina published and

distributed almost 10,000 copies of The North Carolina Physicianís Guide to Driver

Medical Evaluation55 to physicians who would likely see medically high-risk patients.

In 2001, Pennsylvania mailed a brochure of its reporting laws to all physicians licensed

in that State. Every year in January, the Wisconsin Department of Motor Vehicles

(DMV) conducts outreach at major hospitals to inform physicians about the purpose and

function of the Wisconsin medical review board. Wisconsin also mails brochures on its

reporting laws to all physicians in the State who are registered with the AMA in order to

reach the rural physician. In 2002 and 2003, Oregon conducted a public awareness

campaign to inform drivers and physicians of newly implemented physician-reporting

laws. This campaign included awareness seminars for physicians and training for social

workers on how to counsel functionally impaired individuals and provide alternative

transportation options.

The AMA and NHTSA have taken steps to inform physicians through their Older

Driver program and the Physicianís Guide to Assessing and Counseling Older Drivers.56

The AMA has also developed a training-of-trainers program, based on the Physicianís

Guide, to educate physicians and other healthcare professionals on the public health issue

of older driver safety and to train them on assessing and counseling patients for medical

fitness to drive. As of September 2004, 24 instructors from various healthcare fields have

been taught the five modules of the training-of-trainers program and have subsequently

conducted about 40 seminars based on the Physicianís Guide throughout the nation.

Upcoming training sessions are listed on the AMA website. 

Dr. Laurel Broadhurst, a practicing physician in North Carolina and advisor for the

North Carolina Driver Medical Evaluation Program, suggested that because physicians in

North Carolina are required to take 150 hours of continuing medical education (CME)

credits every 3 years, one of those hours could cover State reporting laws.57 State CME

requirements vary by State, with 9 States58 and the District of Columbia having no such

requirement, and 39 States requiring that physicians take, on average, between 20 and 50

hours of CME credits annually to maintain their licenses.59 According to the AMA, a few

of the Physicianís Guide training sessions that have been offered have provided CME

credit.60 The Physicianís Guide itself includes a self-administered test and a form for

physicians to apply for CME credits.

55 T.B. Cole, M.L. Vinsant, and C.L. Popkin, The North Carolina Physicianís Guide To Driver Medical

Evaluation, North Carolina Department of Health and Human Services (1995).

56 See Physicianís Guide to Assessing and Counseling Older Drivers <http://www.ama-assn.org/

go/olderdrivers>.

57 Testimony of Dr. Laurel Broadhurst, physician, Family Medicine Associates, NTSB hearing,

Medical Oversight of Noncommercial Drivers, March 18-19, 2003.

58 Colorado, Connecticut, Indiana, Montana, New York, Oregon, South Dakota, Vermont, and Wyoming.

59 American Medical Association, State Medical Licensure Requirements and Statistics, 2004. Some

States have different CME requirements for Doctors of Osteopathy. 

60 Dr. Claire Wang, advisor to the AMA, telephone interview, March 17, 2004.
Medical Oversight 19 Special Investigation Report

Mandatory Reporting. An additional issue that could factor into the level of

physician reporting is the presence of mandatory reporting laws. Currently, Nevada,

California, Delaware, New Jersey, Oregon, and Pennsylvania have laws that require

physicians to report drivers with certain high-risk medical conditions to the licensing

agency (appendix E). As mentioned previously,61 geriatricians in California, where

physicians are required to report drivers with moderate dementia, were more likely to be

aware of State reporting laws than geriatricians nationwide. A 1997 study62 found that in

the five Canadian provinces with mandatory reporting laws, 84 percent of the physicians

reported patients with seizures, as compared to 19 percent in the five provinces with

discretionary laws. A survey63 of physicians in Connecticut, a State that does not have a

mandatory physician reporting law, found that 77 percent discussed driving with their

patients, and 14 percent reported high-risk patients to the licensing authority. Another

survey64 found that 28 percent of individuals at a seizure clinic in Oregon would not

inform their physicians of seizures if a mandatory physician reporting law were

implemented. A 2000 study65 reported that mandatory reporting laws for cardiac patients

in Ontario have only a negligible impact on accident reduction. 

Several differing views about mandatory reporting were expressed during the

Safety Boardís hearing. Dr. Krumholz and Dr. Dana Clarke, Chairman of the Utah

Medical Advisory Board, argued that mandatory reporting would discourage patients from

seeking treatment or disclosing the extent of their illnesses to their physicians. They

believed that physicians should only be encouraged to report to the licensing authorities

any person who is of immediate and imminent danger to the public safety. Dr. Wang

testified that the primary goal of physicians should be to keep their patients on the road

safely as long as possible, through medical interventions, medical treatments, and driver

rehabilitation programs. Only after these options have been exhausted should a doctor

recommend retirement from driving. Dr. Marottoli agreed that mandatory reporting may

not give physicians the flexibility to educate patients and caregivers about impairing

conditions and driving, but he also believed that the risk of not reporting a medically unfit

driver could outweigh the risk of breaching patient-doctor confidentiality. Ms. Jill Reeve,

Program Supervisor of the Medical Review Unit of the Wisconsin Department of

Transportation, favored mandatory reporting because she believed that few physicians

would voluntarily report their patients. 

Liability Concerns. Liability issues may also influence the level of physician

reporting. Dr. Laurel Broadhurst testified that many physicians worry about the liability

61 Cable (2000).

62 R.S. McLachlan, ìMedical Conditions and Driving: Legal Requirements and Approach of

Neurologists,î Med Law, 16(2) (1997): 269-275.

63 M.A. Drickamer and R.A. Marottoli, ìPhysician Responsibility in Driver Assessment,î American

Journal of Medical Science, 306(5) (1993): 277-81.

64 M.C. Salinsky, K. Wegener, and F. Sinnema, ìEpilepsy, Driving Laws, and Patient Disclosure to

Physicians,î Epilepsia, 33(3) (1992): 469-72.

65 C.S. Simpson, G.J. Klein, F.J. Brennan, A.D. Krahn, R. Yee, and A.C. Skanes, ìImpact of a

Mandatory Physician Reporting System for Cardiac Patients Potentially Unfit to Drive,î The Canadian

Journal of Cardiology, 16(10) (2000): 1257-63.
Medical Oversight 20 Special Investigation Report

issues in both reporting high-risk patients and not reporting those individuals. She testified

further that giving physicians immunity from liability would help promote physician

reporting. Dr. Clarke also voiced concern about the absence of immunity statutes in some

States, calling it a barrier that ìencourages non-reporting.î66 Currently, 32 States provide

physicians legal immunity when reporting medically high-risk patients (appendix F);67 18

States and the District of Columbia do not.68 A recent NHTSA-sponsored nationwide

survey of State licensing representatives indicated that providing physicians who report an

unfit driver with immunity from liability was among the five most important elements to

have in a model medical oversight program.69

Emergency Medical Technicians

Emergency medical technicians (EMTs) and paramedics are among the first

individuals called to an automobile crash. They are trained in lifesaving procedures and

the identification of certain medical conditions. According to Mr. Richard Wiederhold,

District Chief of the Brevard County Public Safety Department in Florida, EMTs in most

States have a responsibility by law to report the medical treatment that they provide to

patients. This report is sent to the medical recordkeeping agency of the State, is not made

public, and is not shared with law enforcement. The concept of doctor-patient

confidentiality is extended to EMTs treating the patient because an EMT who responds to

a medical emergency is considered a ìborrowed servant of the physician under whose

license they operate.î 70 The National Association of Emergency Medical Technicians

(NAEMT) believes that some States currently provide legal immunity to EMTs who report

medically impaired drivers, but a list of these State does not exist.71

According to Mr. Wiederhold, no formal mechanism exists for EMTs to report

medically impaired drivers to a physician or licensing authority for purposes of oversight.

Nevertheless, Mr. Wiederhold stated that EMTs do occasionally steer law enforcement

towards checking a driver when impairment is suspected, especially when alcohol is

involved. 

66 Testimony of Dr. Dana Clarke, Chairman of the Utah Medical Advisory Board and Director of the

University of Utah Diabetes Center, NTSB hearing, Medical Oversight of Noncommercial Drivers,

March 18-19, 2003.

67 Contrary to what is published in the Summary of Medical Advisory Board Practice in the United

States, the Safety Board has learned that Connecticut and Nevada do provide immunity to reporting

physicians.

68 Lococo (2003).

69 K. Lococo and L. Staplin, In-Depth Study to Identify Best Practices for Licensing Drivers With

Medical and Functional Impairments and Barriers to Their Implementation, contract #DTNH22-02-P-05111,

National Highway Traffic Safety Administration (2004). 

70 Testimony of Mr. Richard Wiederhold, District Chief of the Brevard County Public Safety

Department, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18 and 19, 2003.

71 NAEMT Board of Directors Government Affairs Liaison, telephone interview, November 20, 2003,

and telephone interview with NAEMT President, April 8, 2004.
Medical Oversight 21 Special Investigation Report

Law Enforcement

Law enforcement officers are among the principal individuals who report

medically high-risk drivers to State licensing agencies. In Maryland and North Carolina,

for example, about 35 percent of such reports are submitted by law enforcement officers.72

In Wisconsin, law enforcement officers account for 70 percent of all such referrals; and in

Iowa, for over 90 percent.73 States generally require officers to submit a reexamination form

to report a medically high-risk driver. Some States provide law enforcement with other

referral methods. For example, officers in Florida may also refer an accident driver by

entering an appropriate code in the ìPhysical Defectsî field of the accident form.74 The

Florida DMV reviews the accident forms and contacts those drivers who are identified as

possibly posing a medically related risk. Between 2000 and 2002, using this method, 17,642

accident drivers were referred to the Florida Medical Unit. In North Carolina, if during the

accident report electronic coding process it is discovered that medical impairment may have

contributed to a crash is discovered, the report is routed to the Driver Medical Review

Branch for further scrutiny. If determined that a medical impairment probably played a role

in the crash, the Medical Review Branch contacts the driver with a request for

reexamination.75 During the same timeframe, 43,340 accident drivers were referred to the

North Carolina Medical Review Branch as potentially posing a medically related risk.76 

Accident Reporting Forms. State accident reporting forms vary in the attributes

provided to law enforcement officers to describe a driverís physical condition at the time

of an accident. Floridaís accident reporting form has seven possible driver medical

conditions from which to choose, including ìeyesight defect,î ìillness,î

ìseizure/epilepsy/blackout,î and ìhearing defect.î The Maryland accident reporting form

contains such driver conditions as ìill,î ìphysical defects,î and ìother handicaps.î Using

the Texas accident reporting form, law enforcement officers may select between ìillî and

ìtaking medication,î and the form directs officers to elaborate in the narrative. All State

accident reporting forms include prompts for fatigue, alcohol, and illegal drugs. 

In 1998, NHTSA introduced the Federal guideline Model Minimum Uniform

Crash Criteria (MMUCC), which States can use to modify their accident reporting

forms.77 The goal of MMUCC was to encourage States to voluntarily adopt a uniform

accident reporting form that could be used to generate accurate, reliable, and credible data

72 Testimony of Dr. Carl Soderstrom, Associate Director of the Medical Advisory Board for the

Maryland Motor Vehicle Administration, and Susan M. Stewart, Manager of North Carolinaís Driver

License Medical Review Section, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18

and 19, 2003.

73 See <http://www.nhtsa.dot.gov/people/injury/olddrive/FamilynFriends/state.htm>.

74 Management Analyst III, Division of Driver Licenses, Florida Department of Highway Safety and

Motor Vehicles (DHSMV), telephone interview, April 12, 2004.

75 Testimony of Dr. Laurel Broadhurst, Weaverville Family Medicine, NTSB hearing, Medical

Oversight of Noncommercial Drivers, March 18 and 19, 2003. 

76 Susan Steward, Manager, North Carolina Division of Motor Vehicles, Driver Medical Review

Branch, telephone interview, May 2004.

77 U.S. Department of Transportation, National Highway Traffic Safety Administration, The Model

Minimum Uniform Crash Criteria, Second Edition (Washington DC: NHTSA, 2003). 
Medical Oversight 22 Special Investigation Report

for use at the State and national level. In terms of functional impairment, the MMUCC

contains fields concerning suspected drug or alcohol use and a field that refers to a driverís

condition at the time of the crash. According to the MMUCC, attributes to be considered

under the driverís condition field include driver emotion (depressed, angry, or disturbed),

signs of illness, signs of fatigue or sleepiness, and the influence of medications, drugs, or

alcohol. NHTSA does not track the number of States that have adopted all or part of the

MMUCC, but is currently working on having this information available by 2005.78

Training. In January 2004, NHTSA published the Compendium of Law

Enforcement Older Driver Programs.

79 The primary intent of the Compendium is to

document strategies used by law enforcement agencies throughout the nation to reduce

collisions involving older drivers. These strategies include partnerships with senior citizen

organizations, family help networks, social service agencies, public and private

transportation, the media, and motor vehicle departments. The Compendium also includes

training programs, aimed at older adults and caregivers, for identifying signs of dementia

and other medical impairments associated with aging. Law enforcement agencies from 28

States provided NHTSA with information for the Compendium. Agencies from nine States

noted that they have specific courses or educational material to train officers in identifying

symptoms of Alzheimerís disease. Only Florida indicated that it had educational material

available to law enforcement officers for identifying other high-risk medical conditions,

such as Parkinsonís disease, visual impairment, and arthritis. In many cases, the agencies

that responded addressed training only for their district or region, so the availability of

courses or training materials for officers statewide is unclear.

According to Sargeant Robert Ticer, an Arizona Department of Public Safety law

enforcement officer and author of the Compendium, officer training in health matters

consists mainly of first aid instruction at the police academy.80 Some officers in rural areas

are trained as EMTs as a matter of necessity. About 5,000 officers nationally have also

been trained as drug recognition experts (DREs), their primary focus being the

identification of individuals who are driving under the influence of alcohol or other

commonly abused drugs.81 Sargeant Ticer testified that, in general, law enforcement

officers are not aware of the issues regarding medical impairment and driving and are not

trained to recognize signs of medical impairment. Patrick Judge, the executive director of

the International Association of Directors of Law Enforcement Standards and Training

(IADLEST) supported Sargeant Ticerís testimony, stating that several emerging programs

are aimed at increasing the awareness of officers to all aspects of driver impairment, but

for the most part, such training is not currently offered at the police academies.82

78 NHTSA team leader, State Data and Quality Assurance Team, telephone interview,

September 15, 2004.

79 See <http://www.nhtsa.dot.gov/people/injury/olddrive/LawEnforcementOlderDriver03/index.htm>.

80 Testimony of Sargeant Robert Ticer, Arizona Highway Patrol, NTSB hearing, Medical Oversight of

Noncommercial Drivers, March 18-19, 2003.

81 Officers specially trained to detect possible signs of drug impairment through a personís appearance

or behavior, or through psychophysical testing. A 12-step evaluation process allows the officer to rule in or

out many medical conditions that may be contributing to the personís impairment.

82 IADLEST Executive Director, telephone interview, November 12, 2003.
Medical Oversight 23 Special Investigation Report

The Public

Support from family, friends, and other caregivers plays a significant role in a

medically high-risk individualís decision to stop driving.83 Nevertheless, driving cessation

can be a difficult topic for caregivers to broach with a medically high-risk driver.84 In

many States, family members and private citizens have the option to report a medically

high-risk individual to the State licensing authority. However, one hindrance to reporting

is the lack of immunity from civil liability suits given to private citizens who report a

medically high-risk driver in good faith: as few as 16 States offer immunity to individuals

who report an unfit driver in good faith.85 (See appendix F for a summary of State

immunity laws.)

The New York State Office for the Aging notes that those who deal with a

medically high-risk individual often need: (1) help in coping with a medically impaired

individual, (2) options for treatment and rehabilitation, (3) information about referral

procedures, and (4) information about alternative transportation. According to Dr. Dobbs

of the University of Alberta, several good resources are available to friends and family

members, including the New York State Office for the Agingís When You Are

Concerned.

86 However, she stated that many families do not know that these resources

exist or how to access them. 

One easily accessible source of information is a Stateís motor vehicle Web site.

The Safety Board visited 16 motor vehicle Web sites87 and found that half contained no

information on the Stateís medical oversight program. Four motor vehicle Web sites

contained medical oversight information that was either sparse, difficult to locate, or

contained legal jargon. Only the Virginia, New York, California, and Massachusetts Web

sites provided easy-to-access links to senior services, reporting procedures, and other

medical oversight information.

State Oversight

Licensing drivers is a State function, and each State has a unique system to manage

the licensure of medically high-risk drivers. During the Safety Boardís hearing, State

representatives from Maryland, North Carolina, Wisconsin, and Utah discussed their

licensing and oversight systems. Differences were evident in several important areas,

including the identification, referral, and assessment of medically high-risk drivers;

83 J.E. Johnson, ìOlder Rural Adults and the Decision to Stop Driving: The Influence of Family and

Friends,î Journal of Community Health Nursing, 15(4) (1998): 205-16.

84 Cotrell (1999).

85 Federal Highway Administration, Update of Medical Review Practices and Procedures in U.S. and

Canadian Commercial Driver Licensing Programs, DT FH61-95-P-01200 (Washington, DC: FHWA, 1997).

86 When You Are Concerned: A Guide for Families Concerned About the Safety of an Older Driver,

New York State Office for the Aging, Albany, New York (2000).

87 Alabama, Alaska, Arkansas, Arizona, Connecticut, Maine, Maryland, Massachusetts, New York,

New Hampshire, New Jersey, Pennsylvania, Rhode Island, Vermont, Virginia, and California.
Medical Oversight 24 Special Investigation Report

license examiner training; the existence and responsibility of medical advisory boards; the

appeals process; and the availability of information and counseling for drivers whose

licenses have been restricted or denied. 

No standards or guidelines currently exist on which States can model their medical

oversight system. In June 2003, NHTSA published the results of a comprehensive survey

of State medical oversight programs.88 The purpose of this survey was to learn the

following: 

ï The organizational structure of each Stateís medical program.

ï The mechanisms States use to identify drivers with medical conditions and

functional impairments.

ï The procedures and medical guidelines used to evaluate drivers for fitness-todrive. 

ï The evaluation outcomes, appeal of licensing action, and availability of

counseling and public information and educational materials.

ï Administrative issues, including employee training, driver tracking systems,

and barriers to implementing more extensive screening, counseling, and

referral activities. 

According to the American Association of Motor Vehicle Administrators

(AAMVA), which assisted in this project, the survey is a step toward compiling a list of

best practices that States may adopt to improve their medical oversight programs.89 

Consistent with testimony given at the Safety Boardís public hearing, the NHTSA

survey results revealed a wide variety of procedures regarding how States obtain, assess,

and respond to information on drivers with medical impairments. For example, although

virtually all States accept referrals from family members, some do not accept referrals

from friends and other citizens. Fewer than half of the States investigate referrals before

contacting the driver. A driver involved in multiple crashes within a certain time period

would trigger an evaluation in about a fourth of the States, whereas a fatal crash would

trigger an evaluation in about half of the States. States also differ in the training given to

licensing agency staff on identifying impairing conditions, in the composition and

responsibilities given to medical advisory boards, and in the information and counseling

given to those found medically unfit to drive. (See table 3 for selected responses from the

NHTSA survey.)

Table 4 summarizes the medical oversight system of four representative States,

further illustrating the various methods that have been instituted to manage medically

high-risk drivers. Appendix G describes these four medical oversight systems in more

detail using information from the NHTSA survey, the Safety Board hearing, and

correspondence with State officials. 

88 Lococo (2003). 

89 See <http://www.aamva.org>.
Medical Oversight 25 Special Investigation Report

Table 3. Selected State survey responses from the 2003 Summary of Medical Advisory 

Board Practices in the United States, NHTSA.

*The courts or the driver may request a copy of the report, depending on the State involved.

**California has a medical advisory board, which is currently inactive. Nevada has a medical advisory board on paper only.

State Responses

Identification Yes No Conditional

Reports by physicians confidential. 6 2 43*

Reporting physician has legal immunity from legal actions by 

their patients.

32 19

Licensing agency accepts referrals from friends and other 

citizens.

39 12

Licensing agency accepts anonymous referrals. 6 45

Referrals investigated before contacting driver. 24 27

Multiple crashes trigger an evaluation. 15 36

A fatal crash triggers an evaluation. 25 26

In the six mandatory reporting States, a physician who fails to 

report can be held liable as a proximate cause of a subsequent 

crash caused by patient.

3 3

In the six mandatory reporting States, failure of a physician to 

report can lead to summary offense.

1 5

Evaluation

Training given to DMV front desk staff to identify impairing 

conditions.

20 31

Licensing agency has automated system to track medical 

records.

15 36

Licensing agency allows those diagnosed with Alzheimerís to 

drive.

50 1

Licensing agency has an active** medical advisory board. 35 16

Licensing agency has internal medical review unit with 

designated staff.

24 27

Response

Licensing agency makes public information and education 

materials available regarding fitness to drive and impairing 

conditions.

13 38

Licensing agency provides counseling to drivers with functional 

impairments.

10 41
Medical Oversight 26 Special Investigation Report

Table 4. Summary of State oversight systems.

* California DMV does not track referral volumes.

Reporting Pennsylvania Maryland California Wisconsin

Physicians Required to report 

medically unsafe 

drivers. Immunity 

given.

Encouraged and 

not required to 

report medically 

unsafe drivers. 

Immunity given.

Required to 

report persons 

diagnosed with 

condition characterized by lapses 

of consciousness. 

Immunity given.

Encouraged and 

not required to 

report medically 

unsafe drivers. 

Immunity given.

Public Immunity given. 

No anonymous 

referrals accepted.

Immunity given. 

Anonymous 

referrals accepted.

Immunity given. 

Anonymous 

referrals accepted 

from family.

Immunity given. 

Anonymous 

referrals 

accepted.

Law 

enforcement

Accident form 

includes fields that 

inquire about 

driver condition.

Refers drivers by 

submitting a 

ìRequest for 

Reexaminationî to 

the MAB. 

Can submit a 

ìregularî or a 

ìpriorityî 

reexamination to 

Medical Unit.

Refers drivers by 

submitting a 

ìDriver Behavior 

or Conditionî 

report.

Referrals

Annually N/A 13,700 N/A* 3,800

From 

physicians

16,000 17 percent ~20,000 10 percent

From law 

enforcement

2,500 35 percent N/A > 60 percent

From the 

public

500 11 percent N/A 10 percent

Denials, 

suspensions, 

revocations

~7,200 ~1,200 N/A >1,900

Other sources 

(self-reports, 

DMV, court 

system)

N/A 35 percent from 

self reports.

N/A 20 percent from 

DMV staff 

evaluations.

Medical unit

Trained 

nonmedical staff 

who review all 

cases.

12 registered 

nurses who prepare 

case information 

for MAB.

249 nonmedical 

staff who review 

all cases.

8 nonmedical staff 

and one registered 

nurse who review 

all cases.

Medical 

advisory 

board

Composition 13 physicians 16 physicians Inactive 152 physicians

Primary duties Administrative and 

advisory. Rarely 

reviews individuals 

cases.

Reviews cases; 

advises MVA.

Only activated to 

revise medical 

evaluation 

guidelines.

Evaluates 

appeals; advises 

Wisconsin DOT.

Outreach

PennDOT published 

and distributed 

Physician Reporting 

Fact Sheet in 2001.

None None Mails brochures 

on its reporting 

laws yearly to 

physicians.
Medical Oversight 27 Special Investigation Report

Recently, two organizations published reports that recommended strategies for

improving aspects of State medical oversight programs. In July 2004, the Transportation

Research Board (TRB) published a guide90 for reducing collisions involving older drivers.

The TRBís guide outlined a strategy to ìidentify older drivers at increased risk of crashing

and interveneî and recommended that each State ìcreate and support a strong and activeî

medical advisory board and post information concerning the board on its motor vehicle

department and medical association Web sites to inform the general public and healthcare

community about the advisory boardís existence and role. 

The guide further recommended that States update their guidelines for licensing

individuals with medical conditions or functional impairments and encourage the reporting of

impaired drivers by driver licensing staff, physicians, law enforcement, and the general public.

The guide provides strategies and instruction to help States meet these goals. For example, to

encourage the reporting of drivers with functional impairments, the guide suggests:

1. Having the necessary systems in place, including any needed reporting forms.

2. Publicizing the systems to physicians, at driver licensing offices, on

department of motor vehicle Web sites.

3. Making reports confidential (but not necessarily anonymous).

4. Providing appropriate training and materials to law enforcement officers.

5. Working with the MAB and State medical association to help educate

physicians and other health professionals. 

6. Having a system in place to follow up on the resulting referrals.

In August 2004, the American Automobile Association (AAA) Foundation

released a list of 10 Best Practices for Medical Advisory/Review Boards.91 (See appendix

H.) The list was based upon the surveys conducted by NHTSA and AAMVA. As with the

TRB report, the AAA Foundation recommended that each State establish a medical

advisory board with the authority to develop State medical licensing guidelines, review

cases, and recommend customized/restricted licenses and periodic driver testing.

Alternative Transportation

A 2001 National Household Travel Survey produced by the Bureau of

Transportation Statistics found that 9 percent of all Americans, and about 24 percent of

those over 65, report having a medical condition that makes it difficult for them to travel

90 I. Potts, J. Stutts, R. Pfefer, R.R. Neuman, K.L Slack, and K.K. Hardy, A Guide For Reducing

Collisions Involving Older Drivers, National Cooperative Highway Research Program Report 500, Vol. 9

(Washington, DC: TRB, 2004).

91 <http://www.aaanewsroom.net/Files/seniorbestpractices.doc>.
Medical Oversight 28 Special Investigation Report

outside the home.92 Studies consistently show that individuals associate driving with

independence and perceptions of self-worth and that cessation from driving is often

accompanied by increases in inactivity, loneliness, and depression.93,94,95 At the Safety

Boardís hearing, physicians and advocacy groups generally agreed that an individualís

license should be revoked only after other avenues of treatment, rehabilitation, and

restrictions are exhausted. During the hearing, the American Association of Retired

Persons (AARP), the Epilepsy Foundation, and WHEELS of Wellness96 discussed the

problems facing their constituents and the initiatives in place to solve them. 

Ms. Mary Jane OíGara, an AARP Board of Directors member, testified on the

negative impact driving cessation can have on seniors, especially those living in rural

areas that are not serviced by alternative transportation.97 She described the AARP Driver

Safety program, a driver safety course that has been taught for 30 years. This course

makes senior drivers aware of the physiological changes that accompany aging and the

adjustments that are necessary to continue driving safely. The AARP Driver Safety

program also addresses the effect that medical conditions and medications can have on

driving ability and skill. According to Ms. OíGara, the AARP is working actively with

other institutions to promote awareness among seniors, caregivers, and physicians

regarding the impact that aging-related diseases can have on driving skills. The

organization is also working with States and the Federal Government to improve roadway

lighting, signage, and design with senior drivers in mind.

Ms. Alexandra Finucane, Vice President of Legal and Government Affairs for the

Epilepsy Foundation, testified that the Hagerstown and Fredrick, Maryland, accidents

showed that education aimed at physicians and the general public about epilepsy is still

inadequate.98 According to Ms. Finucane, the Epilepsy Foundation has tried to increase

awareness among policymakers that epilepsy can be treated and that the risk of subsequent

seizures can be predicted from previous seizures. The Foundation has worked closely with

neurologists to make them aware of the importance of talking with their patients about

their disease and the associated driving risks. Additionally, in 1992, the Epilepsy

Foundation, along with the American Academy of Neurology and the American Epilepsy

92 U.S. Department of Transportation, Bureau of Transportation Statistics, Highlights, 2001 National

Household Travel Survey.

93 Dobbs and Dobbs (2003). 

94 R.A. Marottoli, C.F.M. de Leon, T.A. Glass, C.S. Williams, L.M. Cooney, Jr., L.F. Berkman, and

M.E. Tinetti, ìDriving Cessation and Increased Depressive Symptoms: Prospective Evidence from the New

Haven EPESE, Established Populations for Epidemiologic Studies of the Elderly,î Journal of the American

Geriatric Society, 45(2) (1997): 202-6.

95 R.A. Marottoli, C.F.M. de Leon, T.A. Glass, C.S. Williams, L.M. Cooney, Jr., and L.F. Berkman,

ìConsequences of Driving Cessation: Decreased Out-of-Home Activity Levels,î The Journals of

Gerontology Series B: Psychological Sciences and Social Sciences, 55(6) (2000): S334-40.

96 A charitable organization that provides alternative transportation services in the Philadelphia area.

97 Testimony of Ms. Mary Jane OíGara, Board of Directors member, AARP, NTSB hearing, Medical

Oversight of Noncommercial Drivers, March 18 and 19, 2003.

98 Testimony of Alexandra Finucane, Vice President of Legal and Government Affairs, Epilepsy

Foundation of America, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18 and 19, 2003.
Medical Oversight 29 Special Investigation Report

Society, drafted model regulations and sample statutory provisions on assessment and

licensure for persons with epilepsy that could be adopted by State policymakers.99

Both witnesses voiced concern over the lack of alternative forms of transportation.

Ms. OíGara stated that about 20 percent of nondrivers 75 years or older use public

transportation on a monthly basis, and suggested that improved sensitivity training for

drivers, accessible and sheltered bus stops, and well-maintained sidewalks might increase

ridership. Ms. Finucane recalled a survey that found that the most important issues

for people with epilepsy and their families were transportation and employment, two issues

that are closely related.100 She added that because epilepsy is an episodic disorder that

only occasionally manifests itself in the occurrence of a seizure, many with epilepsy are

told that they do not qualify for paratransit101 service due to the apparent absence of a

functional limitation. Ms. Judith Ward, Government Relations Director of the Epilepsy

Foundation, further added that some forms of paratransit are age-dependent for eligibility,

thereby precluding their use by many with epilepsy.102

Mr. Reginald Knowlton, Executive Director of WHEELS of Wellness,

acknowledged during the hearing that the accessibility of alternative transportation could

depend on such issues as a personís residence, age, and travel purpose.103 According to Mr.

Knowlton, rural service is generally spotty although some programs, like the Capital Area

Rural Transportation System104 in Texas, offer good coverage. He added that many

transportation options are available for healthy persons over the age of 65, but fewer are

available for seniors with significant medical conditions. Transportation options are also

available for those under 65 who are covered by Medicaid. However, Medicaid only

covers medically related transportation costs and cannot be used for work and most

activities of daily living. Mr. Knowlton added that nonprofit transportation programs are

available for those not covered by Medicaid, but these can accommodate only a limited

number of people.

99 American Academy of Neurology, American Epilepsy Society, and Epilepsy Foundation of America,

ìConsensus Statements, Sample Statutory Provisions, and Model Regulations Regarding Driver Licensing

and Epilepsy,î Epilepsia, 35(3) (1994): 696-705.

100 The 2002 Epilepsy Foundation Annual Report states that the unemployment rate among those with

epilepsy is at least 25 percent.

101 According to the Community Transportation Association <www.ctaa.org/ntrc/glossary.asp>,

ìParatransit includes types of passenger transportation that are more flexible than conventional fixed-route

transit but more structured than the use of private automobiles. Paratransit includes demand-response

transportation services, subscription bus services, shared-ride taxis, car pooling and vanpooling, jitney

services, and so on. Most often refers to wheelchair-accessible, demand-response van service.î

102 Testimony of Ms. Judith Ward, Government Relations Senior Director, Epilepsy Foundation of

America, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003.

103 Testimony of Reginald ìRexî Knowlton, Executive Director, WHEELS of Wellness, NTSB hearing,

Medical Oversight of Noncommercial Drivers, March 18-19, 2003.

104 The Capital Area Rural Transportation System, or CARTS, delivers transportation tailored

specifically for each of the 123 communities it serves. Service frequency in the various locales ranges from

several times a day to once a month. Four intermodal transit facilities combine a variety of transportation

options including fixed route, commuter vans, intercity, interstate motor coach passenger freight service,

carpool, taxi and intracounty, intercity, and local paratransit services. See <http://www.ridecarts.com> for

more information.
Medical Oversight 30 Special Investigation Report

Dr. Broadhurst, physician and advisor to the North Carolina Driver Medical

Evaluation Program, provided an example of paratransit options in rural North Carolina:

Mountain Mobility, a Government-funded program for Medicare and Medicaid recipients.

According to Dr. Broadhurst, individuals who qualify for the transportation program must

make an appointment, sometimes a week in advance. The limited number of vans

available limits the serviceís convenience, to the point where patients who use Mountain

Mobility to visit a health clinic might have to wait all day before being picked up for the

return trip home.

Mr. Knowlton noted that a primary reason for the discrepancies in alternative

transportation service among different groups is that several different private, State, and

Federal funding sources exist, but many do not communicate with each other. In addition,

each funding source requires the transport provider to abide by a set of rules that is often

incompatible often are incompatible with the rules of other funding sources. Mr.

Knowlton noted further that communication is improving, especially at the Federal level,

where the U.S. Department of Transportation (DOT) and the U.S. Department of Health

and Human Services105 (HHS) are trying to coordinate their efforts through the

Coordinating Council on Access and Mobility (CCAM).106 

Mr. Knowltonís testimony is supported by a June 2003 report107 by the U.S.

Government Accountability Office (GAO), which identified 62 Federal programs that

fund transportation services for the transportation-disadvantaged.108 Most of these

programs are funded through four agencies. HHS operates the largest number of these

programs (23), with the DOT (6), U.S. Department of Labor (DOL-15), and U.S.

Department of Education (ED-8) operating a large share of the rest. The Federal

Government spent over $2.4 billion in 2001 on these programs, with States and

municipalities providing additional funding. 

The GAO report recognized the combined efforts of the DOT and HHS, but noted

the possibility of further coordination with the DOL and ED in the CCAM. The GAO

acknowledged that several obstacles currently hinder coordination, including (1) a

reluctance to share resources because of concern among the agencies that their own

program recipients might be negatively affected, (2) different eligibility requirements,

safety standards, and other programmatic requirements that limit the ability to share

resources, and (3) a lack of leadership and commitment to coordinate and limited guidance

and information on coordination. To mitigate these obstacles, the GAO report suggested

105 HHS funds transportation through such activities as Medicaid, Medicare, the Older Americans Act,

Temporary Assistance to Needy Families, and Head Start.

106 The CCAM is a joint project by the Departments of Transportation and Health and Human Services

to assist in providing transportation for persons who are somehow disadvantaged in their ability to obtain

their own transportation.

107 U.S. General Accounting Office, Transportation Disadvantaged Populations: Some Coordination

Efforts Among Programs Providing Transportation Services, but Obstacles Persist, Report GAO-03-697

(Washington, DC: GAO, 2003).

108 The transportation-disadvantaged include seniors, the medically impaired, low-income adults and

students, native Americans, and veterans.
Medical Oversight 31 Special Investigation Report

making Federal standards more consistent, creating a clearinghouse to facilitate

interagency communication and to provide better guidance on coordination, and providing

financial incentives or instituting mandates to coordinate transportation services.

In February 2004, the GAO published a memo to Congress updating the

information in its June 2003 report.109 According to this memo, ED and DOL have since

been invited to participate in the CCAM. Some of the agencies within DOL and ED have

already linked their Web sites to the CCAM Web site or have plans to do so. In December

2003, the four Federal agencies launched a five-part coordination initiative called ìUnited

We Rideî (appendix I) to establish an interagency forum and to provide States and

communities with incentives to coordinate. The GAO report also stated that although the

DOT, HHS, DOL, and ED ìhave indicated that they plan to consider including

information on coordinating transportation services for the transportation-disadvantaged

in their next strategic and annual performance plansÖ.only FTA [Federal Transit

Administration] has demonstrated progress in this area at this time.î

Public Policy

During the final session of the Safety Boardís public hearing on the medical

oversight of noncommercial drivers, witnesses from NHTSA, the AAMVA, and the

National Conference of State Legislatures (NCSL) suggested systemic improvements that

could reduce accidents caused by individuals who have high-risk medical conditions. 

Mr. James Reed, NCSL Program Director of Transportation, voiced his support for

unified State laws on mandatory physician reporting,110 stating his belief that such a

system would decrease the number of crashes related to medical impairments because

information about an individual driverís condition would be reported and tracked through

a prescribed procedure. Further research would be needed to determine the conditions and

level of impairment that would require reporting. Mr. Reed acknowledged that mandatory

reporting might discourage patients from seeking treatment or disclosing the extent of

their illnesses to their physicians, but believed that the potential benefits to public safety

outweighed these obstacles.

Mr. Reed also believed that all applicants renewing their licenses or obtaining

licenses for the first time should be required to answer a questionnaire regarding their

health and to sign an affidavit to the veracity of their answers. Although individuals might

still falsify information, he stated that the imposition of liability might be enough to deter

most individuals from providing false information. According to Mr. Reed, subsidized

109 U.S. General Accounting Office, Transportation-Disadvantage Populations: Federal Agencies Are

Taking Steps to Assist States and Local Agencies in Coordinating Transportation Services, Report GAO-04-420R

(Washington, DC: GAO, 2004).

110 Testimony of James Reed, Transportation Program Director, National Conference of State

Legislatures, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003.
Medical Oversight 32 Special Investigation Report

alternative transportation should be provided to those who admit or are found to have a

debilitating condition that would preclude them from driving safely.

Dr. Richard Compton of NHTSA cautioned that the extent of medically related

crashes is not known because national data on this topic do not exist.111 He testified that

although the licensing of noncommercial drivers is not a Federal function, NHTSA works

closely with State associations and institutions to improve licensing practices throughout

the nation. Dr. Compton stated that more research is needed on the effectiveness of driver

restriction, and awareness and training programs are needed for all parties involved in the

oversight process, including physicians and law enforcement. Finally, Dr. Compton

suggested more programs be established to counsel drivers who should restrict or cease

driving.

Mr. Mike Calvin, Senior Vice President of AAMVA, testified that research is still

needed to determine how medical and cognitive factors affect driving and what can be

done to address these issues effectively.112 He noted that AAMVA has taken steps toward

this goal, contributing to the publication of ìFunctional Aspects of Driver Impairment: A

Guide for State Medical Advisory Boardsî113 and the Physicianís Guide to Assessing and

Counseling Older Drivers. Mr. Calvin added that AAMVA also contributed to the NHTSA

report summarizing U.S. Medical Advisory Board Practices and is actively involved with

evaluating medical review process. Mr. Calvin stated that the identification of best

practices should encourage the development of model laws, which could be used to

promote uniformity between jurisdictions. 

Since the hearing, AAMVA and NHTSA have made progress toward identifying

the best practices in a medical oversight program. In October 2003, NHTSA, AAMVA,

and TransAnalytics114 surveyed State licensing representatives to rank the importance of

64 medical oversight ìbest practiceî elements that were identified from previous work on

the Summary of Medical Advisory Boards in the United States (appendix J).115 The survey

results were compiled into a NHTSA interim report.116 State licensing representatives

rated physician reporting of high-risk drivers as the most important element. Other highly

rated elements included the development of medical criteria and guidelines for licensing;

the development of standards for blackouts, seizures, and losses of consciousness; and the

provision of immunity to physicians who report a high-risk driver to the State licensing

agency.

111 Testimony of Dr. Richard Compton, Director, Office of Research and Technology, National

Highway Traffic Safety Administration, NTSB hearing, Medical Oversight on Noncommercial Drivers,

March 18-19, 2003.

112 Testimony of Mike Calvin, Senior Vice President, American Association of Motor Vehicle

Administrators, NTSB hearing, Medical Oversight of Noncommercial Drivers, March 18-19, 2003.

113 ìFunctional Aspects of Driver Impairment: A Guide for State Medical Advisory Boards,î Guidelines

for Motor Vehicle Administrators, DOT HS 805 460 (Washington, DC: NHTSA and AAMVA, 1980).

114 Consulting firm working on NHTSA-sponsored contract on medical oversight.

115 Lococo (2003).

116 Lococo and Staplin (2004).
Medical Oversight 33 Special Investigation Report

State representatives, invited by NHTSA, AAMVA, and TransAnalytics to discuss

the survey results, unanimously agreed that a national association of medical advisory

boards should be formed to draft guidelines for licensing drivers with medical conditions

and functional impairments.117 The representatives also believed that physicians were a

critical component to an effective medical oversight system and that steps should be taken

to facilitate their participation in the medical oversight process, including providing

physicians with immunity from liability, implementing mandatory reporting laws,

providing physicians with CME credits for medical oversight training, and enabling

physicians to get reimbursed for patient assessment and counseling.

117 Lococo and Staplin (2004).
34 Special Investigation Report

Previous Safety Board Actions

The Safety Board has encountered several types of impairing medical conditions

in its accident investigations over the past two decades, including diabetes, cardiovascular

disease, sleep disorders, visual disorders, and alcohol and drug dependency. The

investigations cited in appendix B involved commercial drivers, who are required to meet

a stricter level of fitness, as defined in the Code of Federal Regulations (CFR).118

Commercial drivers are also required to undergo a medical examination every 2 years to

certify their fitness to operate a commercial vehicle. These accidents are relevant to this

discussion because (1) State licensing agencies learn about medically high-risk

commercial and noncommercial drivers in much the same way; (2) State licensing

agencies are responsible for evaluating and overseeing the licensure of both commercial

and noncommercial drivers; (3) a commercial driverís license is valid for both commercial

and noncommercial vehicle operations; and (4) Federal fitness regulations do not require

State or Federal authorities to review or track the results of commercial driver medical

examinations.119

Medical Oversight of Commercial Drivers

In 2001, the Safety Board called for a system-wide modification to the medical

oversight of commercial drivers following a medical impairment-related motorcoach

accident that occurred on May 9, 1999.120 In that accident, a 1997 Motor Coach Industries

55-passenger motorcoach traveling eastbound on Interstate 610 in New Orleans,

Louisiana, drifted from the roadway, vaulted over a golf cart path, and collided with a dirt

embankment. A total of 22 passengers were killed, the busdriver and 15 passengers

received serious injuries, and 6 passengers received minor injuries. The ensuing

investigation established that the 46-year-old driver suffered from several life-threatening

medical conditions of the kidneys and heart. The Safety Board established the probable

cause of the accident as the ìdriverís incapacitation due to his severe medical conditions

and the failure of the medical certification process to detect and remove the driver from

service.î The Board recommended that the Federal Motor Carrier Safety Administration

(FMCSA) develop a comprehensive medical oversight program for interstate commercial

drivers that would contain the following program elements:

118 Title 49 CFR 391.43 specifies the health criteria that must be met by all interstate commercial

drivers. Every State has also adopted regulations based on these Federal requirements for their intrastate

commercial drivers.

119 Some States do require proof of fitness before granting or renewing a commercial driverís license.

For a more detailed description and analysis of the commercial driver medical oversight system, see

National Transportation Safety Board, Motorcoach Run-Off-The-Road, New Orleans, Louisiana, May 9,

1999, Highway Accident Report NTSB/HAR-01/01 (Washington DC: NTSB, 2001).

120 See appendix C for a summary of commercial driver medical oversight recommendations that were

issued as a result of this accident.
Previous Safety Board Actions 35 Special Investigation Report

H-01-17

Individuals performing medical examinations for drivers are qualified to

do so and are educated about occupational issues for drivers. 

H-01-18

A tracking mechanism is established that ensures that every prior

application by an individual for medical certification is recorded and

reviewed. 

H-01-19

Medical certification regulations are updated periodically to permit trained

examiners to clearly determine whether drivers with common medical

conditions should be issued a medical certificate. 

H-01-20

Individuals performing examinations have specific guidance and a readily

identifiable source of information for questions on such examinations.

H-01-21

The review process prevents, or identifies and corrects, the inappropriate

issuance of medical certification. 

H-01-22

Enforcement authorities can identify invalid medical certification during

safety inspections and routine stops.

H-01-23

Enforcement authorities can prevent an uncertified driver from driving

until an appropriate medical examination takes place. 

H-01-24

Mechanisms for reporting medical conditions to the medical certification

and reviewing authority and for evaluating these conditions between

medical certification exams are in place; individuals, healthcare providers,

and employers are aware of these mechanisms. 

In addition, the Safety Board recommended that the AAMVA urge its member

States to develop a comprehensive medical oversight program for intrastate commercial

drivers containing the same eight elements (Safety Recommendation H-01-26). 
Previous Safety Board Actions 36 Special Investigation Report

The Safety Board also recommended the following to the NCSL:

H-01-27

Inform State legislatures about this accident and make them aware of the

importance of establishing immunity laws for the good-faith reporting of

potentially impaired commercial drivers by all individuals and of ensuring

that the medical community and the commercial transportation industry are

familiar with these laws.

Since the Safety Board made these recommendations, the FMCSA has created a

Medical Division within the Administration and continues to work toward an effective

commercial driver medical oversight system. The FMCSA plans to publish a notice of

proposed rulemaking (NPRM) in early 2005 on the merger of the medical certificate with the

commercial driverís license to reduce the number of inappropriate medical certificates that

are issued.121 Furthermore, the FMCSA has indicated that efforts are underway to create a

medical advisory board to review the Federal regulations on commercial driver medical

qualifications, to advise the FMCSA on any needed modifications, and to establish a medical

examinerís registry model. The FMCSA has also requested funds to establish a national

registry of qualified medical examiners and a certification process to better ensure that all

medical examiners are qualified to perform commercial driver fitness examinations. 122 

In response to the Safety Boardís recommendation to inform State legislatures

about the New Orleans motorcoach accident and the importance of immunity laws, the

NCSL published an article on its Internet publication, Transportation Notes, which

highlighted the Boardís recommendations. The formal responses of the FMCSA,

AAMVA, and the NCSL, as well as the current status of each recommendation, are

provided in appendix C.

Over-the-Counter and Prescription Medications

The Safety Board has investigated many accidents in all passenger transportation

modes in which the use of licit medications by vehicle operators has been causal or

contributory. As a result of these accident investigations, the Board issued

recommendations to the DOT to create a list of over-the-counter and prescription drugs

that have been found to be safe for use during vehicle operation and to prohibit

commercial vehicle operators from using drugs that are not on this list (Safety

Recommendations I-00-1 through -4). The Board also issued recommendations to the

FMCSA to establish and implement an educational and information dissemination

program to make commercial vehicle operators aware of the hazards of using specific

medications when driving (Safety Recommendations H-00-13 and -14) and to establish

121 FMCSA telephone correspondence, August 19, 2004.

122 FMCSA has included these projects in its 2003-2004 funding request. This request, as is all surface

transportation funding, is pending. 
Previous Safety Board Actions 37 Special Investigation Report

procedures or criteria for those vehicle operators who might require medication not on the

DOTís list of approved medications (Safety Recommendation H-00-12). Additionally, the

Safety Board recommended that the Food and Drug Administration (FDA) establish a

clear, consistent, easily recognizable warning label for all prescription and over-thecounter medications that may interfere with an individualís ability to operate a vehicle and

to require that the label be prominently displayed on all packaging of such medications

(Safety Recommendation I-00-5).

On November 14 and 15, 2001, the Safety Board and the FDA held a public forum

on transportation safety and potentially sedating and impairing medications. This forum

included experts from the DOT and the Federal Railroad Administration. FDA and DOT

representatives met again on July 31, 2002, and April 17, 2003, to further discuss the

recommendations. The FDA indicated that it was willing to revise labeling and standards

related to drug-induced vehicle operator impairment, but did not possess the technical

expertise to evaluate vehicle operator impairment standards and measures and did not

have sufficient funds to do the necessary research and analysis. The DOT concurred with

the intent of the recommendations but voiced some concern about the work involved in

reviewing all medications to determine and list those that do not impair vehicle operators

and about the regulatory effort required to enforce such a list.

The DOT modal offices have taken several positive actions relating to the use of

medications by vehicle operators. For example, the FTA has (1) begun to educate transit

employees on the effects of prescription and over-the-counter medications, (2) incorporated

this information into seminars on drug and alcohol issues, and (3) issued guidelines for the

safe use of medications that have been included in the quarterly FTA Drug and Alcohol

program newsletter. Additionally, NHTSA has indicated a willingness to collaborate with the

FDA to develop standard protocols for evaluating vehicle operator impairment due to

medications and has a proven record of successfully funding similar research and analysis.

The Safety Board recognizes that the collaboration between the FDA and NHTSA

may form the basis for an acceptable alternative response by the DOT and modal agencies

to these recommendations and may advance the goal of reducing the use of performanceimpairing over-the-counter and prescription medications by vehicle operators. Pending

completion of a collaborative effort between NHTSA and the FDA to develop druginduced impairment standards for vehicle operators and pending appropriate subsequent

action by the DOT, Safety Recommendations H-00-12 through -14 are classified

ìOpenóAcceptable Alternate Response.î

Alcohol Addiction

In June 2000, the Safety Board examined the progress made in reducing fatalities,

injuries, and crashes involving hard-core drinking drivers.123 A hard-core drinking driver

123 National Transportation Safety Board, Actions to Reduce Fatalities, Injuries, and Crashes Involving

the Hard-Core Drinking Driver, Safety Report NTSB/SR-00/01 (Washington, DC: NTSB, 2000).
Previous Safety Board Actions 38 Special Investigation Report

is defined as an individual with multiple driving while intoxicated (DWI) convictions in

the past 10 years or who registered a blood alcohol content (BAC) of .15 percent or more

during the first arrest. This alcohol-dependent group was responsible for 70,239 traffic

fatalities from 1993 to 2002, and for 6,610 highway fatalities in 2003 alone, at an

estimated cost in 2003 of around $6.5 billion.124 

In conducting its research, the Safety Board reviewed the literature on

countermeasures that have been found effective in reducing recidivism, crashes, fatalities,

and injuries. The Board found that in the 15 years since its last examination of the hardcore drinking driver issue, every State had made strides toward addressing this major

safety problem. Despite this progress, the measures taken and the degree of

implementation have not been uniform, and 17,013 people still died in 2003 from alcoholrelated crashes. As a result of its most recent examination into the hard-core drinking

driver issue, the Board made the following recommendation to the Governors and

legislatures of the 50 States and the mayor and council of the District of Columbia:

H-00-26

Establish a comprehensive program that is designed to reduce the

incidence of alcohol-related crashes, injuries, and fatalities caused by hardcore core drinking drivers and that includes elements such as those

suggested in the National Transportation Safety Boardís Model Program.125

Since the Safety Boardís recommendation was issued, all States have considered

legislation related to the Boardís recommendation, and 31 States have adopted one or

more elements of the model program. No State has all of the elements recommended in the

Boardís model program; however, sufficient progress has been made to classify this

recommendation ìClosedñAcceptable Actionî in three States (New Hampshire, Ohio, and

Utah).126 The Safety Board also recommended the following to the DOT: 

124 Based upon an economic cost of $977,000 per traffic fatality. See Blincoe, The Economic Impact of

Motor Vehicle Crashes 2000.

125 The Board believes that a model program to reduce hard-core drinking driving would incorporate the

following elements: (1) statewide sobriety checkpoints; (2) vehicle sanctions to restrict or separate hard-core

drinking drivers from their vehicles; (3) State and community cooperative programs to enforce DWI driverís

license suspension and revocation; (4) legislation to require that DWI offenders maintain a zero BAC while

operating a motor vehicle; (5) legislation that defines a high BAC (0.15 percent or greater) as an

ìaggravatedî DWI offense; (6) alternatives to confinement, such as home detention with electronic

monitoring; (7) legislation that restricts the plea bargaining of a DWI offense to a lesser, non-alcohol-related

offense; (8) elimination of diversion programs that permit erasing, deferring, or otherwise purging the DWI

offense record or that allow the offender to avoid license suspension; (9) administrative license revocation

for BAC test failure and refusal; (10) a DWI record retention and DWI offense enhancement look-back

period of at least 10 years; and (11) individualized sanction programs for hard core DWI offenders.

126 See <http://www.ntsb.gov/recs/mostwanted/hard_core_drinking.htm> for a comprehensive list of

elements incorporated by each State.
Previous Safety Board Actions 39 Special Investigation Report

H-00-27

Evaluate modifications to the provisions of the Transportation Equity Act

for the 21stCentury so that it can be more effective in assisting the States to

reduce the hard-core drinking driver problem. Recommend changes

to Congress as appropriate. Considerations should include (a) a revised

definition of ìrepeat offenderî to include administrative actions on drivingwhile-impaired offenses; (b) mandatory treatment for hard-core offenders;

(c) a minimum period of 10 years for records retention and driving-whileimpaired offense enhancement; (d) administratively imposed vehicle

sanctions for hard-core drinking drivers; (e) elimination of community

service as an alternative to incarceration; and (f) inclusion of home

detention with electronic monitoring as an alternative to incarceration.

In response to this recommendation, the DOT asked for funding to make impaireddriving grants available to States that either have a high number of impaired-driving

fatalities or a high impaired-driving fatality rate.127 These grants will be used to help the

States develop and implement programs to significantly reduce alcohol-related fatalities.

In combination with NHTSAís focus on the 13 States with high numbers of alcohol-related

fatalities, the grants emphasizing impaired driving will include repeat offenders. As a

result of the DOTís efforts, the Safety Board classified this recommendation ìClosedó

Acceptable Alternate Action.î

127 Funding was requested by the Safe, Accountable, Flexible and Efficient Transportation Equity Act of

2003 (SAFETEA), which would authorize the Federal surface transportation programs for highways,

highway safety, and transit from 2004 to 2009. As of this reportís publication date, Congress had not passed

SAFETEA.
40 Special Investigation Report

Analysis

This analysis examines the current state of oversight for medically high-risk

drivers in light of the six accidents described in this report and summarizes relevant expert

testimony provided at the Safety Boardís public hearing. This analysis also discusses the

limitations and barriers to a more effective medical oversight system and provides

recommendations to further improve highway safety. 

The six accidents described earlier in this report occurred as a result of the driverís

medical incapacitation. All drivers possessed a valid driverís license. All had a high-risk

medical condition that had been identified, diagnosed, and treated by a physician. None of

the four accident drivers for whom the Safety Board obtained license information

(Hagerstown, Frederick, Lady Lake, and Washington County) were under any type of

driving restriction. Despite their impairments, apparently only the Hagerstown driver had

not received clearance to drive by a physician at the time of the accident. 

Five of the six accidents involved a driver who experienced a seizure, and one

involved a driver who might have experienced a blackout due to her diabetes. The Safety

Board has encountered other types of high-risk medical conditions in previous accident

investigations, including cardiovascular disease, renal disease, sleep disorders, visual

disorders, and alcohol and drug dependency. Although most of these investigations

involved commercial drivers, the license issued to commercial drivers is valid for both

private and commercial vehicle operation, and significant overlap exists in State medical

oversight responsibilities for commercial and noncommercial drivers.

The conditions and events that culminated in these accidents point to several

aspects of State medical oversight that need further scrutiny. Expert witnesses attending

the Safety Boardís public hearing cited additional issues that were not necessarily factors

in the accident investigations, but are equally relevant to improving State medical

oversight. The Safety Board investigations and the hearing identified the following safety

issues:

ï The need for more data on the extent to which medical conditions contribute to

the cause of accident.

ï The need for improved awareness and training for healthcare professionals,

law enforcement, and the public regarding State medical oversight laws and

practices.

ï The existence of barriers to the reporting of medically impaired drivers.

ï The lack of uniform medical assessment and oversight standards throughout

the States.

ï Deficiencies in alternative transportation options for those who should not

drive.
Analysis 41 Special Investigation Report

The following sections will address each of safety issues. In each section, the

issues will be outlined, current initiatives identified, and additional solutions

recommended for reducing crashes related to medical impairment.

Data

Tens of millions of Americans have medical conditions that place them at risk of

becoming incapacitated while driving. However, apart from alcohol addiction, the extent

to which medical impairment contributes to the number of traffic accidents is not well

defined. Safety Board investigations have shown that medical incapacitation can lead to

traffic accidents. Research studies have found a correlation between certain medical

conditions and an increased risk of accident involvement, although no agreement has been

reached on the degree of risk associated with each type of condition. Nonetheless,

research128 shows that the accident risk associated with some medical conditions

approaches, or even exceeds, that for alcohol and drug use (table 2). Based on the

available research and the Safety Boardís accident investigations, the Board concludes

that many medical conditions are associated with increased accident risk and incompatible

with the unrestricted operation of motor vehicles. 

Witnesses at the public hearing agreed that certain medical conditions present an

increased accident risk, but some believed that not enough is known about the number of

medically high-risk drivers and the direct risks that medical conditions present to justify

setting policy based on this information. The Safety Board recognizes that more data

would be useful on the number of licensed drivers with high-risk medical conditions and

on accidents that can be directly linked to these medical conditions. As demonstrated by

the Hagerstown accident investigation, licensing agencies cannot simply rely on drivers to

disclose their medical status during licensing and renewals.

Finding a direct link between medical conditions and accidents would be useful for

determining the risks posed by certain medical conditions. Establishing such a link would

require improved awareness and training for law enforcement and other parties who

witness driver behavior in traffic accidents and would require a system to transfer this

information to the appropriate licensing authorities. The Safety Board learned that North

Carolina and Florida have systems that inform the motor vehicle medical unit when a

driverís medical condition is suspected to have caused an accident. This mechanism

resulted in 17,642 driver referrals in Florida and 43,340 referrals in North Carolina, from

2000 through 2002. The public hearing revealed that not all States have such a system in

place. And, as will be discussed later, only a few States provide the training that could help

law enforcement officers identify a medically impaired driver. 

Accident reporting forms provide a potentially rich source of data on medical

impairment, assuming that law enforcement can be properly trained to identify and

describe signs of impairment. The MMUCC, the Federal guideline on accident reporting

128 Diller (1999).
Analysis 42 Special Investigation Report

form content, recommends that State accident forms include a field for a driverís

condition at the time of the crash. This field functions as an umbrella for various

attributes, including fatigue/sleepiness, alcohol/illegal substances/medication, acute

emotional states (for instance, angry or disturbed), and illness. Although most States have

included a variation of the driver condition field in their accident reporting forms, each

interprets the fieldís purpose somewhat differently, as indicated by the different attributes

listed for the field. In addition, the medical attributes listed on the MMUCC and most

State accident forms are often too general to collect much useful information regarding the

driverís medical condition at the time of the crash. As a result, the value of the driver

condition field in yielding valid, reliable data on medical impairment nationwide is

limited. A field in the MMUCC dedicated to impairing medical conditions would be a

useful source of data for gauging the correlation between driver medical impairment and

accidents. The Safety Board concludes that a system is needed for the collection of

accident data on a national basis to comprehensively evaluate the extent to which medical

conditions play a role in accident causation. The Board believes that NHTSA, in

cooperation with the AMA and the AAMVA, should develop a procedure to periodically

collect, evaluate, and report data, on a State and national basis, regarding the extent to

which medical conditions contribute to the cause of accidents.

Information and Training

Physicians and the Public

During the Safety Boardís hearing on medical oversight, the medical advisor to the

AMAís Older Drivers Project stated that most of the 670,000 physicians involved with

patient care are not knowledgeable about their Stateís reporting policies and procedures or

about the evaluation of patients for their fitness to drive. This assessment is supported by

the research literature, which suggests that many physicians are unfamiliar with medical

oversight laws pertaining to them, and that a physicianís specialty and practice location

can influence his or her knowledge of these laws.129, 130 Of the three medically related

accidents for which the Safety Board obtained medical records (Hagerstown, Frederick,

and Lady Lake), it was evident that the neurologists involved in the treatment of the

accident drivers were aware of their Statesí reporting laws. By contrast, the Hagerstown

driverís family physicianís recommendation that the driver not drive ìthis weekî suggests

that he was not aware of Marylandís 3-month restriction on driving following a seizure.131

The AMAís Physicianís Guide to Assessing and Counseling Older Drivers

includes information to educate healthcare professionals about State reporting laws,

129 Selmo (1997).

130 Cable (2000).

131 At the time of the accident, Maryland could not legally suspend or revoke the license of a seizure

sufferer for more than 90 days. This statute was changed in October 2003 to allow Maryland to suspend or

revoke an individualís driverís license, or refuse or renew a license, for longer than 90 days if that

individualís driving may be adversely affected by seizure.
Analysis 43 Special Investigation Report

identifying and assessing the driving fitness of patients, and proper counseling techniques.

The Physicianís Guide is an invaluable resource for those physicians who are aware of it.

The AMA has also developed a training-of-trainers program, based on the Physicianís

Guide, to reach as many physicians and healthcare professionals as possible. As of

September 2004, 24 healthcare professionals have completed all five modules of the

training-of-trainers program and have taught about 40 seminars nationwide based on the

Physicianís Guide. Nevertheless, witnesses at the hearing acknowledged that further

efforts were needed to reach all physicians, including those that practice in rural areas.

This testimony suggested that medical schools could do more to train students to be aware

of how medical conditions can affect driver safety. Other testimony at the hearing

indicated that this training should include proper assessment techniques because medical

conditions can affect the safety of each driver differently. 

One North Carolina physician, who serves as advisor for the North Carolina Driver

Medical Evaluation Program, suggested that State reporting laws and procedures be taught

as part of a physicianís CME; however, nine States and the District of Columbia currently

do not have a CME requirement for their physicians. The training associated with the

AMAís Physicianís Guide would satisfactorily fill this need, and CME credits have been

offered at these training sessions.132 Three CME credits are also offered to those physicians

who complete the self-administered test on the back of the Physicianís Guide. Since most

States require their physicians to compile CME credits to stay licensed, associating the

Physicianís Guide training with CME credits provides a good incentive for this training.

It is particularly important that physicians be knowledgeable of their Statesí

medical oversight program, of driver assessment procedures, and of driver counseling

because they are often the primary source of this information for caregivers, family, and

friends who have noticed deterioration in a driverís skills. These individuals are generally

not well informed about the reporting laws in their States or of the rehabilitation or

transportation options available to medically high-risk drivers. Unfortunately, this

information is not always readily available. For example, in a review of 16 State licensing

agency Web sites, only 4 contained easily accessible and simple-to-understand

information on medical oversight or on the resources available for those with high-risk

medical conditions. Of the remaining 12 Web sites surveyed, 4 contained information on

older drivers or medical impairment that was either too sparse, too difficult to find, or too

difficult to understand to be useful, and 8 contained no pertinent information at all. The

Safety Board concludes that healthcare providers and concerned citizens may not have

adequate information on resource availability or on the medical oversight laws and

procedures for their States to assist medically high-risk drivers, which impedes their

ability to aid in the safety and well-being of medically high-risk drivers. The Safety Board

will advise the driver licensing agencies in the 50 States and the District of Columbia of

the importance of making guidance information and medical oversight referral procedures

easy to access and easy to understand. 

132 Dr. Claire Wang, telephone interview, March 16, 2004.
Analysis 44 Special Investigation Report

Hearing testimony indicated that many practicing physicians are unaware of their

Statesí medical oversight laws because they lack information and training. Although the

AMAís Physicianís Guide and accompanying training program will help, the concern is

that this program might not reach all physicians, especially those who practice in rural

areas or are not affiliated with a hospital. It is imperative that the medical community be

aware of the thousands of fatalities and millions of injuries that occur annually on U.S.

roadways, and of their responsibility in preventing medically high-risk drivers from

further contributing to these numbers. Therefore, the Safety Board believes that the

Liaison Committee on Medical Education133 (LCME), the American Osteopathic

Association134 (AOA), and the Association of American Medical Colleges135 (AAMC)

should require medical schools to teach students about the driving risks associated with

certain medical conditions and medications, the existence and function of State reporting

laws regarding medically high-risk drivers, and the methods and resources for counseling

such drivers. In addition, the Safety Board believes that the Federation of State Medical

Boards136 (FSMB) should work with its member organizations to ensure that CME

requirements in all States include a course addressing the driving risks associated with

certain medical conditions and medications, as well as the existence and function of State

reporting laws and procedures regarding medically impaired drivers. 

Law Enforcement 

Law enforcement officers often witness unsafe driving behaviors and incapacitated

drivers. However, most are not trained to consider or identify medical impairment during

traffic stops or accident investigations. Testimony at the hearing indicated that although

some officers receive supplemental training helpful in identifying alcohol- or drugimpaired drivers, medical impairments are rarely even considered in this training. 

The executive director of the IADLEST stated that several emerging programs are

aimed at increasing officer awareness of all driver impairment aspects, but for the most

part, such training is not currently offered at police academies. NHTSAís Compendium of

Law Enforcement Older Driver Programs generally supports these statements. The

Compendium lists several programs in which law enforcement agencies have supported

the efforts of senior citizen organizations, family help networks, social service agencies,

public and private transportation, the media, and motor vehicle departments in educating

seniors about medical conditions associated with aging. However, the Compendium lists

133 The nationally recognized accrediting authority for medical education programs leading to the M.D.

degree in U.S. and Canadian medical schools. The LCME is sponsored by the AAMC and the AMA.

134 The primary certifying body for osteopathic physicians and the accrediting agency for all osteopathic

medical colleges and healthcare facilities.

135 An association of medical schools, teaching hospitals, and academic societies with the goal of

improving the nationís health through the advancement of medical schools and teaching hospitals.

136 A national organization comprising the 70 medical boards of the United States, the District of

Columbia, Puerto Rico, Guam, and the U.S. Virgin Islands, with the goal of improving the quality, safety

and integrity of healthcare in the United States by promoting high standards for physician licensure and

practice. The FSMB is also the parent organization of the Accreditation Council for Continuing Medical

Education.
Analysis 45 Special Investigation Report

only a few programs that are aimed at educating the officers about medical impairment,

and most of these are not offered nationwide. 

Increasing law enforcement officer awareness of medically impairing conditions is

paramount in fostering the ability of law enforcement officers to report medically unfit

drivers to the licensing agency. The absence of nationwide medical awareness training for

officers suggests a lack of awareness of the risks that impairing medical conditions can

pose. The Safety Board concludes that a lack of specific training may hinder many law

enforcement officers in the ability to identify signs of driver medical impairment. The

Safety Board therefore believes that the Commission on Accreditation for Law

Enforcement Agencies (CALEA)137 should work with NHTSA, IADLEST, and the AMA

to develop a training program to help police officers identify common medical conditions

that can impair a driverís ability to operate a motor vehicle and then promote this training

to all new and veteran officers.

Reporting

Physicians

In addition to the lack of easily accessible information regarding State oversight

laws, concerns about doctor-patient confidentiality and civil suits have been cited as

further barriers to physician reporting. Six States currently require physicians to report

medically high-risk drivers to the licensing authority. Several physicians at the public

hearing voiced concern over mandatory reporting, stating that it infringes on patient

privacy, compromises their ability to counsel patients on treatment options, and negatively

affects the physician-patient relationship. As discussed previously, research suggests that

mandatory reporting might also discourage patients from seeking treatment or disclosing

the extent of their illness to physicians to continue driving. This reluctance on the part of

patients could result in untreated or misdiagnosed drivers who then potentially present an

even greater threat to all road users. 

Other physicians and State license administrators at the public hearing favored

mandatory reporting and argued that physicians are generally reluctant to report patients

when no requirement exists to do so, even though patients clearly should not be driving.

This is exemplified by the actions of the Frederick accident driverís neurologist, who

stated to the Maryland MVA MAB that the driverís epilepsy was well controlled and that

the driver was ìreliable in taking medications,î despite medical record entries to the

contrary. Research indicates that physicians practicing in States that have mandatory

reporting laws are more aware of those laws and are more apt to report high-risk drivers to

the licensing authority.138 Mandatory reporting laws relieve physicians of the burden of

137 CALEA develops law enforcement standards and establishes and administers an accreditation

process through which law enforcement agencies demonstrate voluntarily that they meet professionally

recognized management and service criteria (<http://www.calea.org>).

138 Cable (2000).
Analysis 46 Special Investigation Report

assessing driving fitness and deliberating the ethical, legal, financial, and social merits of

reporting high-risk patients, making the State licensing agency solely responsible for

determining an individualís fitness to drive. 

Most States encourage, but do not require, physicians to report medically high-risk

drivers to the licensing authority. Research is inconclusive regarding which physician

reporting procedure most effectively identifies and removes medically unsafe drivers.

Although the few studies that have been conducted indicate that physicians file more

reports when a mandatory reporting law is in place, it is unclear whether this is due to the

law itself or to a combination of factors, such as the accessibility of reporting information,

the presence of immunity laws, or more effective reporting procedures. Moreover, it has

not yet been determined whether, in States with mandatory reporting, a significant number

of medically high-risk drivers are dissuaded from disclosing their condition and symptoms

to their physicians. 

During the public hearing, witnesses testified that another hindrance to effective

medical oversight in some States was the absence of immunity laws to protect physicians

who report medically impaired drivers to the licensing authority. The chairman of the Utah

Medical Advisory Board, called it a barrier that ìencourages non-reporting.î According to

the Physicianís Guide and research by the Safety Board, 18 States and the District of

Columbia still do not offer immunity to physicians or to other healthcare providers.

Moreover, as few as 16 States offer immunity to individuals outside the healthcare field

who report an unfit driver in good faith (appendix F).139 In a recent survey sponsored by

NHTSA, State licensing representatives ranked physician immunity from liability among

the top five medical oversight components in terms of importance. 

The Safety Board addressed this issue in its report on the 1999 New Orleans

motorcoach crash,140 and recommended that the NCSL make its members aware of the

importance of establishing immunity laws for the good-faith reporting of potentially

impaired commercial drivers by all individuals and of ensuring that the medical

community and the commercial transportation industry are familiar with these laws

(Safety Recommendation H-01-27). The NCSL complied with the Boardís

recommendation and published an article on its Internet publication, Transportation

Notes, highlighting the Boardís recommendations.

The Safety Board appreciates the NCSLís efforts but believes that if model

legislation were available to protect those who report medically unsafe drivers to the

licensing authority, it would encourage and assist the States in enacting such laws. The

Safety Board concludes that the absence of laws that allow for the good-faith reporting of

medically impaired drivers could hinder the effectiveness of State oversight systems. The

Safety Board believes that the National Committee on Uniform Traffic Laws and

Ordinances should work with the National Association of Attorneys General to develop a

model law that provides immunity from liability for any person (such as a healthcare

139 Update of Medical Review Practices and Procedures in U.S. and Canadian Commercial Driver

Licensing Programs, DT FH61-95-P-01200, Federal Highway Administration (Washington, DC: FHWA, 1997). 

140 NTSB/HAR-01/01. 
Analysis 47 Special Investigation Report

worker, an emergency medical technician, a family member, or a concerned citizen) who,

in good faith, reports a driver with a potentially impairing medical condition, and also

encourage the States to include this law in their statutes. 

Emergency Medical Technicians

EMTs, among the first to respond to an accident, are trained in lifesaving

procedures and the identification of certain medical conditions. They are required in most

States to submit a report on the medical treatment they administer for each accident, which

is sent to the medical record-keeping agency of the State and kept confidential. Licensing

agencies do not have access to these reports. Because EMTs are witnesses to crash scenes,

have the background to identify some impairing medical conditions, and have a close

working relationship with law enforcement officers and emergency room physicians, EMTs

can be an invaluable source for the reporting of medically impaired drivers. However,

according to the NAEMT and the testimony provided by Mr. Wiederhold, District Chief of

the Floridaís Brevard County Public Safety Department, no formal mechanism is currently

in place for EMTs to report medically impaired drivers. The Safety Board therefore

concludes that EMTs are a trained and potentially valuable, but underutilized, resource in

the reporting of medically impaired drivers. The Safety Board appreciates that many of the

same arguments made against physician reporting, such as impingement upon patient

confidentiality and the possible refusal of treatment, can be made regarding EMTs.

However, because EMTs are in a position that allows them to make a causal determination

regarding medical impairment in an accident, their participation is essential in ensuring an

effective State medical oversight program and in reducing the 42,000 annual traffic-related

fatalities. Because EMTs work closely with law enforcement and physicians, States might

be able to employ reporting procedures established for those groups to route EMT driver

impairment information to the proper licensing authorities. The Safety Board, therefore,

believes that the National Committee of Uniform Traffic Laws and Ordinances should

develop model legislation, in conjunction with the National Association of Emergency

Medical Technicians and the National Association of State EMS Directors, that allows

information gathered by EMTs concerning the potential medical impairment of accidentinvolved drivers to be conveyed to the State licensing authority. 

Reporting Accidents

During the hearing, several witnesses expressed the need for more research to

establish a link between medical impairment and driving. Although most studies have

found that drivers with high-risk medical conditions generally have more accidents,

concern was voiced during the Safety Boardís hearing with regards to the studiesí

methodological limitations, such as small sample size, lack of uniform criteria, lack of

exposure data, and absence of evidence that the crashes were a direct result of driver

medical conditions. Some hearing witnesses believed that because medical conditions can

affect each person differently, the presence of a medical condition was in itself a poor

predictor of an individualís driving risk. 

One predictor of risk that received some support was a driverís history of traffic

accidents. Epilepsy research has shown that previous seizure-related accidents are a good

predictor of future crashes for drivers with epilepsy. The Safety Boardís review of the
Analysis 48 Special Investigation Report

hard-core drinking driver literature also showed a strong correlation between accident

involvement and prior traffic-related convictions.141 Research has shown additional links

between accident history and the risk for future accidents.142, 143, 144, 145 One limitation in

using crash history effectively as a predictor is that many accidents go unreported. In fact,

NHTSA estimates that approximately half of property damage-only crashes, and a fifth of

all injury crashes, are not reported to the police.146 

In the Frederick, Maryland, accident, which resulted in the death of one adult and

three children, Safety Board investigators found that MVA records did not contain the

driverís full accident history, including three property damage accidents and one bodily

injury accident that were also the result of an epileptic seizures. Board investigators were

able to compile this information by reviewing the driverís insurance records and his

vehicleís history report. The absence of the driverís previously verified seizure-related

accident was of particular concern because law enforcement had referred the driver to the

Maryland MAB after the accident, and the MAB had suspended the driverís license.

According to the manager of the Driver Wellness and Safety Division of the Maryland

MVA, accident information would not be posted to a driverís driving record unless an

official charge or summons was issued by investigating police. The Safety Board

contacted 13 other States to determine how they treated accident information and found

that 9 included all police-reported accidents in a driverís record, regardless of whether the

driver received a citation. Two States recorded accidents only when a person was found to

be at fault, and two States listed citations associated with an accident without recording

accident information.147

The Safety Board recognizes that it is not often possible to establish definitively

that a high-risk medical condition contributed to an accident. However, if all accident data

for a driver were tracked, licensing agencies would be better able to determine whether

drivers with multiple accident histories are potential candidates for assessments and onthe-road testing. An individualís particular accident history is a reliable predictor because

it does not rely on aggregate data about a high-risk medical population to determine the

risk level of an individual. Therefore, a driver who has not been involved in an accident is

not put under scrutiny simply because he or she happens to have a medical condition.

141 NTSB/SR-00/01.

142 G. Daignealut, P. Joly, and J.Y. Frigon, J.Y, ìPrevious Convictions or Accidents and the Risk of

Subsequent Accidents of Older Drivers,î Accident Analysis and Prevention, 34 (2002): 257-261. 

143 D. Zuin, H. Ortiz, D. Bromei, and O.L. Lopez, ìMotor Vehicle Crashes and Abnormal Driving

Behaviours in Patients with Dementia in Mendoza, Argentina,î European Journal of Neurology, 9(1)

(2002): 29-34.

144 L. Staplin, K.H. Lococo, J. Stewart, and L.E. Decina, Safe Mobility for Older People Notebook,

NHTSA Report DOT-HS-808-853 (Washington, DC: NHTSA, 1999). 

145 K. Ball, C. Owsley, M.E. Sloane, D.L. Roenker, J.R. Bruni, ìVisual Attention Problems as a Predictor of

Vehicle Crashes in Older Drivers,î Investigative Ophthalmology and Visual Science, 34(11) (1993): 3110-23.

146 See <http://www.nhtsa.dot.gov/people/economic/econimpact2000/summary.htm>.

147 New Jersey, Alabama, Utah, Virginia, Nebraska, Florida, Wisconsin, North Carolina, and Tennessee

record all police-reported accidents. Arkansas and Delaware record only at-fault accidents, regardless of

whether those drivers receive a citation. West Virginia and Idaho record only the citations associated with an

accident.
Analysis 49 Special Investigation Report

Although a full accident history would not have led licensing officials to identify the

Hagerstown accident driver as a candidate for driver assessment, it might have helped the

Maryland MVA to detect a pattern of crash involvement for the Frederick accident driver.

This, in turn, might have caused the MVA to question the report from the Frederick

driverís neurologist stating that the driver was physically and mentally capable of safely

operating a motor vehicle. It might also have encouraged the MVA to track the driverís

medical condition more attentively. The Safety Board concludes that the exclusion of

certain accidents from a driverís record weakens the ability of licensing agencies to

identify drivers who require further evaluation and assessment for impairing medical

conditions.

During a 7-year period, the Frederick driver was involved in 6 accidents that

resulted in property damage, injury, or death. However, crashes that result in injury or

fatalities are infrequent events.148 In its 2001 report on hardcore drinking drivers, the

Safety Board encouraged States to adopt a 10-year ìlook backî period for drivers with

previous DWI offenses due to the low likelihood of arrest and the need for long-term

measures to change the behavior of hardcore drinking drivers. An extended ìlook backî

period might likewise be beneficial in assessing the driving fitness of those with high-risk

medical conditions.

If a driver were to have an accident outside his or her State of residence, there is no

guarantee that the licensing agency in the State of residence will find out about it. No laws

or formal agreements exist between States to share information about medically related

traffic stops or accidents that involve out-of-state drivers. In addition, States do not

routinely share medical information about a driver during a transfer of residence. When an

individual applies for a license in a new State of residence, the licensing agency

customarily checks the NDR149 to determine whether the individualís license to drive is

currently revoked, suspended, canceled, or denied. However, the NDR only reports

violations and current license suspensions; it does not alert the requesting party to any

driving restrictions an individual might have due to medical impairment, nor to expired

periods of suspension or revocation. Thus, even had the Maryland MVA known about the

Hagerstown accident driverís condition before her move to Pennsylvania in 1992, this

information would not have found its way to PennDOT. The Safety Board concludes that

States do not routinely convey information to one another, or to any central repository,

regarding medical impairment-related accidents or licensing actions, limiting their ability

to track medically high-risk drivers effectively.

The AAMVA is currently working to integrate the NDR and other commercial and

noncommercial driver information repositories into a system called the Driver Record

Information Verification System (DRIVerS).150 This system is being designed to

148 According to NHTSA, roughly 110 injuries occur per 100 million miles traveled (L. Blincoe, A.

Seay, E. Zaloshnja, T. Miller, E. Romano, S. Luchter, and R. Spicer, The Economic Impact of Motor Vehicle

Crashes 2000, DOT HS 809 446 [Washington, DC: NHTSA, 2000]).

149 The NDR is a central repository of information on individuals whose privilege to drive has been

revoked, suspended, canceled, or denied or who have been convicted of serious traffic-related offenses.

150 See <http://www.aamva.org/drivers/drv_AutomatedSystemsDRIVerS.asp>.
Analysis 50 Special Investigation Report

accommodate more than 200 million records, which could potentially include all licensed

drivers in the United States. The Safety Board believes that the AAMVA should modify

DRIVerS to allow licensing agencies to ascertain current and previous medically related

actions on a driverís license (for example, citations, suspensions, revocations, denials, and

cancellations), as well as any current medically related license restrictions, and to ensure

the timely transfer of medically related citation or accident information involving out-ofstate drivers to the licensing State. 

State Oversight

Had the physicians treating the Lady Lake or Hagerstown accident drivers been

practicing in Pennsylvania, they would have been required by law to report the driver to

PennDOT. Had the Frederick driver been licensed in Georgia, his 2001 license suspension

could have lasted 6 months instead of 3. Licensing is a State function, and as illustrated in

the Medical Oversight section of this report, each State has developed a unique system of

oversight for its medically high-risk drivers. States differ in the way they train license

examiners, set policy, inform physicians and the public about their reporting requirements,

identify and refer medically high-risk drivers for assessment, conduct assessments,

deliberate the licensure of medically high-risk drivers, provide due process, track

medically high-risk drivers, impose driving restrictions, and provide counseling or

information to drivers whose licenses have been restricted or denied. States also differ in

their license renewal periods, renewal procedures and options, and testing requirements

during license renewals. To some extent, these differences reflect deficiencies in the

availability and accessibility of information useful in creating an effective medical

oversight system. They also reflect a lack of coordination between the States and an

absence of Federal guidelines that States can use as a basis for their programs. 

These divergent State oversight systems have resulted in significant differences in

the way high-risk drivers are identified and evaluated. For example, driving suspensions

after a seizure range from no required seizure-free interval to up to 18 months. Some

States require those diagnosed with moderate dementia to immediately surrender their

licenses; others have no requirements pertaining to dementia. Some States employ

medical specialists to evaluate drivers, while others use civil servants with no prior

medical experience. Some States provide information and counseling for former drivers,

but many do not. These inconsistencies have the potential of leading to a wide range of

outcomes in licensing countermeasures among States. Because noncommercial drivers are

not restricted in where they may drive, these differences could undermine the intent of an

effective driver screening program in some States. It is important that each State consider

the oversight systems used in other States and share information and experiences to

strengthen the overall effect of its own medical oversight system. The Safety Board

concludes that deficiencies exist in the availability and accessibility of information

necessary for States to identify the most effective countermeasures for restriction,

modification, or prohibition of driving privileges for medically impaired drivers. 
Analysis 51 Special Investigation Report

In June 2003, NHTSA published a report summarizing the Statesí medical

oversight program. This report described each Stateís medical impairment reporting

procedures; identification, evaluation, and evaluation outcome procedures; licensing

appeal processes; and counseling, information, and educational materials. The report also

described the organization and duties assumed by the medical department of each State

licensing agency. The report, according to AAMVA, was the first step in a larger effort to

create a best practices guideline that would encourage the development of model laws that

could be used to promote uniformity among State licensing jurisdictions. Since then,

AAMVA and NHTSA have conducted another survey asking State medical review

representatives to rank the important procedural elements in a medical review program.

The report generated from the survey does not indicate how best to implement these

procedural elements, but it does note suggestions from respondents. From this survey, and

through meetings with jurisdictional representatives and the Driver Fitness working

group, AAMVA and NHTSA hope to generate a best practices report by fall 2004.

The Safety Board is encouraged by the progress that has been made by AAMVA

and NHTSA toward creating a best practices guideline and a model medical oversight

program. The Safety Board anticipates that the adoption of these guidelines by the States

will likely involve significant procedural, regulatory, and statutory changes that may

extend across several agencies, including law enforcement and emergency medical

services. Communication among State representatives will be necessary to facilitate the

sharing of experiences, data, and strategies, so that each State can gather the tools

necessary to implement an effective program while minimizing costs. It is also foreseeable

that advances in medical research, driving assessment tools, and rehabilitation and

counseling programs will necessitate a continual evaluation of the guidelines. The Safety

Board therefore believes that NHTSA, in cooperation with the AAMVA, should:

1. Determine the most effective methods for the comprehensive reporting to State

licensing authorities of drivers who may be medically impaired. 

2. Determine the most effective licensing countermeasures to reduce the risks

posed by medically impaired drivers.

3. Once the most effective reporting methods and licensing countermeasures have

been determined, develop a model comprehensive medical oversight program

for States to use to oversee medically impaired drivers. Such a program should

include, at a minimum:

a. Methods to provide information to the public on resource availability

and on the medical oversight laws and procedures to assist medically

high-risk drivers.

b. Plans and strategies to simplify and maximize reporting of potential

driver medical impairment to medical evaluation units of State driver

licensing organizations by law enforcement officers, healthcare

providers, emergency services providers, and the public.
Analysis 52 Special Investigation Report

c. Methods to capture all cases of motor vehicle incidents or accidents potentially

related to driver medical impairment.

d. Standardized methods of driver evaluation for potentially medically impaired

drivers incorporating medical records review, systematic testing, and on-road

appraisals, as needed.

e. Methods for timely and appropriate restriction of driving privileges for drivers

found to have medical conditions or treatments that impair their ability to safely

operate a motor vehicle. 

The Safety Board also believes that the AAMVA should establish a standing

medical evaluation unit working group to facilitate communication, standardization, and

cooperation among medical evaluation units of member States.

Alternative Transportation 

The Hagerstown driverís medical records indicated that in the 2 years before the

accident, her physician and neurologist had advised her on several occasions that she

should discontinue driving for a certain period of time. In June 2002, her neurologist

documented having told her that she should not drive for the next 6 months. The accident

in Hagerstown occurred within that 6-month time period. On three occasions, her

physicians documented having told the driver to contact the licensing authorities about her

condition. However, there is no evidence that the accident driver ever did so. The driver

refused to speak to Safety Board investigators following the accident, so the Board was

unable to determine why the driver chose not to follow her physiciansí advice and disclose

her medical condition to PennDOT. 

The Hagerstown accident driver lived in a rural area of south-central Pennsylvania,

near the northern border of Maryland. It is possible that a suspension or revocation of her

driverís license would have restricted her ability to find and maintain employment, visit

her physicians, run errands necessary to maintain a household, and conduct social

activities. During the Safety Board hearing on the medical oversight of noncommercial

drivers, participants generally agreed that all options should be exhausted before revoking

a driverís license. Research cited earlier described the symbolic and practical importance

associated with the privilege to drive. Driving cessation is often accompanied by feelings

of depression, loneliness, and isolation. It can limit the ability of individuals to perform

life functions such as shopping, visiting friends, and going to the doctor. For the working

professional, the absence of a license can severely restrict employment options. Hearing

participants agreed that the primary goal of physicians should be to keep their patients on

the road safely as long as possible, through medical interventions, medical treatments, and

driver rehabilitation programs.

Alternative transportation options exist for many whose impairments preclude

licensure, but hearing testimony and GAO research indicate that some populations are
Analysis 53 Special Investigation Report

inadequately served by these accommodations. The GAO found 62 separately funded

Federal programs that provided transportation services for the transportationdisadvantaged, many targeting the same populations. However, hearing witnesses testified

that the coverage and eligibility for these services vary greatly depending on an

individualís place of residence, age, disability, and travel purpose. Testimony also

indicated that alternative transportation services in rural areas are generally ìspottyî and

that services for those under 65 not covered by a Government assistance program can be

limited. The focus on seniors is understandable given their increasing numbers and the

relatively high correlation between aging and impairing diseases, but statistics from the

Epilepsy Foundation151 and Census Bureau152 suggest that medically impaired individuals

of working age are equally in need of alternative transportation services. GAO

recommendations regarding the need for (1) more coordination among Federal agencies,

(2) uniform Federal standards across departments, (3) an information clearinghouse to

facilitate communication and coordination, and (4) financial incentive provisions to States

and localities could eventually result in less duplication of services, the adoption of more

streamlined requirements, and the expansion of services to all demographics. The Safety

Board concludes that current alternative transportation services are insufficient to meet the

needs of all groups of unlicensed, medically impaired individuals. The Safety Board

believes that the DOT should work with HHS, DOL, and ED to develop alternative

transportation programs for medically impaired people of all ages who can no longer

drive. 

151 Epilepsy Foundation 2002 Annual Report.

152 See <http://www.census.gov/Press-Release/www/1999/cb99-fff13.html>.
54 Special Investigation Report

Conclusions

1. Many medical conditions are associated with increased accident risk and

incompatible with the unrestricted operation of motor vehicles.

2. A system is needed for the collection of accident data on a national basis to

comprehensively evaluate the extent to which medical conditions play a role in

accident causation.

3. Healthcare providers and concerned citizens may not have adequate information on

resource availability or on the medical oversight laws and procedures for their States

to assist medically high-risk drivers, which impedes their ability to aid in the safety

and well-being of medically high-risk drivers.

4. A lack of specific training may hinder many law enforcement officers in their ability

to identify signs of driver medical impairment.

5. The absence of laws that allow for the good-faith reporting of medically impaired

drivers could hinder the effectiveness of State oversight systems.

6. Emergency medical technicians are a trained and potentially valuable, but

underutilized, resource in the reporting of medically impaired drivers.

7. The exclusion of certain accidents from a driverís record weakens the ability of

licensing agencies to identify drivers who require further evaluation and assessment

for impairing medical conditions.

8. States do not routinely convey information to one another, or to any central

repository, regarding medical impairment-related accidents or licensing actions,

limiting their ability to track medically high-risk drivers effectively.

9. Deficiencies exist in the availability and accessibility of information necessary for

States to identify the most effective countermeasures for restriction, modification, or

prohibition of driving privileges for medically impaired drivers.

10. Current alternative transportation services are insufficient to meet the needs of all

groups of unlicensed, medically impaired individuals.
55 Special Investigation Report

Recommendations

New Recommendations

To the U.S. Department of Transportation:

Work with the U.S. Department of Health and Human Services, the U.S.

Department of Labor, and the U.S. Department of Education to develop

alternative transportation programs for medically impaired people of all ages who

can no longer drive. (H-04-37)

To the National Highway Traffic Safety Administration:

In cooperation with the American Medical Association and the American

Association of Motor Vehicle Administrators, develop a procedure to periodically

collect, evaluate, and report data, on a State and national basis, regarding the

extent to which medical conditions contribute to the cause of accidents. (H-04-38)

To the National Highway Traffic Safety Administration, in cooperation with the 

American Association of Motor Vehicle Administrators:

Determine the most effective methods for the comprehensive reporting to State

licensing authorities of drivers who may be medically impaired. (H-04-39)

Determine the most effective licensing countermeasures to reduce the risks posed

by medically impaired drivers. (H-04-40)

Once the most effective reporting methods and licensing countermeasures have

been determined, develop a model comprehensive medical oversight program for

States to use to oversee medically impaired drivers. Such a program should

include, as a minimum:

a. Methods to provide information to the public on resource availability

and on the medical oversight laws and procedures to assist medically

high-risk drivers.

b. Plans and strategies to simplify and maximize reporting of potential

driver medical impairment to medical evaluation units of State driver

licensing organizations by law enforcement officers, healthcare

providers, emergency services providers, and the public.

c. Methods to capture all cases of motor vehicle incidents or accidents

potentially related to driver medical impairment.
Recommendations 56 Special Investigation Report

d. Standardized methods of driver evaluation for potentially medically

impaired drivers incorporating medical records review, systematic

testing, and on-road appraisals, as needed.

e. Methods for timely and appropriate restriction of driving privileges for

drivers found to have medical conditions or treatments that impair

their ability to safely operate a motor vehicle. (H-04-41)

To National Committee on Uniform Traffic Laws and Ordinances:

Work with the National Association of Attorneys General to develop a model law

that provides immunity from liability for any person (such as a healthcare worker,

an emergency medical technician, a family member, or a concerned citizen) who,

in good faith, reports a driver with a potentially impairing medical condition, and

also encourage the States to include this law in their statutes. (H-04-42)

Develop model legislation, in conjunction with the National Association of

Emergency Medical Technicians and the National Association of State EMS

Directors, that allows information gathered by emergency medical technicians

concerning the potential medical impairment of accident-involved drivers to be

conveyed to the State licensing authority. (H-04-43)

To the American Association of Motor Vehicle Administrators:

Modify the Driver Record Information Verification System to allow licensing

agencies to ascertain current and previous medically related actions on a driverís

license (for example, citations, suspensions, revocations, denials, and

cancellations), as well as any current medically related license restrictions, and to

ensure the timely transfer of medically related citation or accident information

involving out-of-State drivers to the licensing State. (H-04-44)

Establish a standing medical evaluation unit working group to facilitate

communication, standardization, and cooperation among medical evaluation units

of member States. (H-04-45)

To the Commission on Accreditation for Law Enforcement Agencies:

Work with the National Highway Traffic Safety Administration, the International

Association of Directors of Law Enforcement Standards and Training, and the

American Medical Association to develop a training program to help police

officers identify common medical conditions that can impair a driverís ability to

operate a motor vehicle and then promote this training to all new and veteran

officers. (H-04-46)

To the Liaison Committee on Medical Education, the American Osteopathic Association, and the Association of American Medical Colleges:

Require medical schools to teach students about the driving risks associated with

certain medical conditions and medications, the existence and function of State

reporting laws regarding medically high-risk drivers, and the methods and

resources for counseling such drivers. (H-04-47)
Recommendations 57 Special Investigation Report

To the Federation of State Medical Boards:

Work with your member organizations to ensure that continuing medical

education requirements in all States include a course addressing the driving risks

associated with certain medical conditions and medications, as well as the

existence and function of State reporting laws and procedures regarding medically

impaired drivers. (H-04-48)

Previously Issued Recommendations Classified in This Report

Safety Recommendations H-00-12 through -14 (previously classified ìOpenó

Await Responseî) are classified ìOpenóAcceptable Alternate Responseî in the

ìPrevious Safety Board Actionsî section of this report.

BY THE NATIONAL TRANSPORTATION SAFETY BOARD

ELLEN ENGLEMAN CONNERS CAROL J. CARMODY

Chairman Member

MARK V. ROSENKER RICHARD F. HEALING

Vice Chairman Member

DEBORAH A. P. HERSMAN

Member

Adopted: November 9, 2004

59 Special Investigation Report

Appendix A 

Investigation and Public Hearing

The National Transportation Safety Board was notified of the Hagerstown,

Maryland, accident on November 4, 2000. Investigators were dispatched from the Atlanta

and Washington offices. Groups were established to investigate highway factors, human

performance, and vehicle factors. The Maryland State Police participated in the on-scene

investigation.

Based on the findings of the Hagerstown accident and other accidents involving

medically impaired drivers, the Safety Board conducted a public hearing regarding driver

medical oversight issues on March 18 and 19, 2003, in Washington, D.C. Parties to the

hearing were the American College of Emergency Physicians, the American Medical

Association, the Association for the Advancement of Automotive Medicine, the

Association for Driver Rehabilitation Specialists, the American Association of Retired

Persons, the American Sleep Apnea Association, the Alzheimerís Association, the

Epilepsy Foundation of America, the Parkinsonís Disease Foundation, the Advocates for

Highway and Auto Safety, the American Insurance Association, Mothers Against Drunk

Driving, the American Association of Motor Vehicle Administrators, the Governors

Highway Safety Association, the National Committee on Uniform Traffic Laws and

Ordinances, the National Conference of State Legislatures, the Centers for Disease

Control and Prevention, the Federal Transit Administration, and the National Highway

Traffic Safety Administration.
60 Special Investigation Report

Appendix B

Medically Related Safety Board Highway Investigations

Accidents in which the driverís medical condition may have been a factor

Report 

number

Date Description Location Medical condition(s)

HAR83/05February 

1983

Head-on collision of dump 

truck and school bus

Willow Creek, 

California

Diabetes

HAR86/02May 1985 Multivehicle collision Snow Hill, 

North 

Carolina

Posttraumatic epilepsy; did 

not take medication as 

prescribed

HAR87/01August 

1985

Intercity bus loss of 

control and collision with 

bridge rail

Frederick, 

Maryland

Diabetes, high blood 

pressure, recent kidney 

transplant

HAR87/04May 1986 Intercity bus loss of 

control and rollover

Walker, 

California

Diabetes

HAR88/03September 

1987

Intercity bus run off the 

road and overturn

Middletown, 

New Jersey

Diabetes

HAR89/03November 

1988

Motorcoach loss of 

control and overturn

Nashville, 

Tennessee

Cardiovascular disease

CRH-92-

FH004

December 

1991

Two trucks Arlington, 

Texas

Sleep apnea

CRH-93-

TH015

January 

1993

Propane truck overturn Arlington, 

Texas

Sleep apnea

HWY-98-

FH004

October 

1997

School bus struck by load 

from a tractor-semitrailer

Franklin, 

North 

Carolina

Alcohol addiction 

HWY-98-

F-H019

October 

1997

Motorcoach loss of 

control

New York, 

New York

Seizure-like episode in 1992 

attributed to alcohol 

detoxification

HWY-98-

MH022

March 

1998

School bus struck by a 

train

Buffalo, 

Montana

Poor vision

HWY-98-

F-H045

September 

1998

School bus collision with 

dump truck

Holmdel, 

New Jersey

Migraines

HAR01/01May 1999 Motorcoach run off the 

road

New Orleans, 

Louisiana

Diagnosed cardiovascular 

and kidney disease, drug 

addiction

HAR02/01July 2000 Police cruiser struck by a 

tractor-semitrailer

Jackson, 

Tennessee

Diagnosed sleep apnea
61 Special Investigation Report

Appendix C

Commercial Driver Medical Oversight Recommendations

Each of the following recommendations, which were issued as a result of the

Safety Boardís investigation of a bus crash that occurred in New Orleans, Louisiana, on

May 9, 1999, specifies a component to be developed as part of a comprehensive medical

oversight program for interstate commercial drivers. The Safety Board believes that the

medical oversight of commercial drivers is so critical an issue that these recommendations

are included in its ìMost Wantedî list. The latest classification of these recommendations

occurred in September 2004.

Federal Motor Carrier Safety Administration (FMCSA)

The Safety Board recommended that the FMCSA develop a comprehensive

medical oversight program for interstate commercial drivers that contains the elements

noted in Safety Recommendations H-01-17 through -24 discussed below.

H-01-17

Individuals performing medical examinations for drivers are qualified to

do so and are educated about occupational issues for drivers.

In an August 31, 2004, letter to the Safety Board, the FMCSA stated that it is

establishing a national registry of qualified medical examiners and a certification process.

According to the FMCSA, the registry will enable specific training and continuous

national monitoring of medical examiners on the registry and can be used to disseminate

information to practitioners regarding new medical discoveries, policies, or requirements

relevant to the examinations. Furthermore, a certification program will ensure that

medical examiners are qualified and educated about the occupational issues for drivers

and have specific guidance and a readily identifiable source of information for questions

concerning the physical examinations. The FMCSA has requested funding for the registry

and certification process, developed a statement of work, and issued a request for

proposals. Pending the establishment of the registry and certification process, Safety

Recommendation H-01-17 has been classified ìOpenñAcceptable Response.î 

H-01-18

A tracking mechanism is established that ensures that every prior

application by an individual for medical certification is recorded and

reviewed.
62 Special Investigation Report

In its April 11, 2002, response to the Safety Board on this recommendation, the

FMCSA stated that Section 215 of the Motor Carrier Safety Improvement Act of 1999

(Public Law 106-159, 113 Stat. 1748 [December 9, 1999]) requires that medical

certification be part of the commercial driverís license. Consequently, the FMCSA was

researching various approaches for such a tracking and reviewing mechanism. The

FMCSA also stated that it would work with the States and with industry to explore

alternatives that would simplify both compliance and enforcement of the regulations.

Pending the establishment of a tracking system, on September 26, 2002, the Safety Board

classified Safety Recommendation H-01-18 ìOpenóAcceptable Response.î

H-01-19

Medical certification regulations are updated periodically to permit

trained examiners to clearly determine whether drivers with common

medical conditions should be issued a medical certificate.

In an August 31, 2004, letter to the Safety Board, the FMCSA stated that it was

establishing a nationally recognized expert medical review board to make

recommendations concerning commercial vehicle drivers and for revising medical

standards. Among the medical review boardís other duties are to review and to interpret

medical research to support regulatory and policy development and to provide the

FMCSA with an authoritative resource of medical expertise for making decisions on

commercial driver medical and physical qualifications. Although the FMCSA has yet to

receive funding from Congress to establish a medical review board, it has already

developed a statement of work and has issued a request for proposals. Pending the

establishment of the medical review board, Safety Recommendation H-01-19 has been

classified ìOpenóAcceptable Response.î

H-01-20

Individuals performing examinations have specific guidance and a readily

identifiable source of information for questions on such examinations.

In its August 31, 2004, letter to the Safety Board, the FMCSA stated that it is

establishing a national registry of qualified medical examiners and a certification process.

According to the FMCSA, this will enable specific training and continuous national

monitoring of the medical examiners on the registry and can be used to disseminate

information to practitioners regarding new medical discoveries, policies, or requirements

relevant to the examinations. Furthermore, a certification program will ensure that

medical examiners are qualified and educated about the occupational issues for

commercial drivers and have specific guidance and a readily identifiable information

resource for questions concerning the physical examinations. The FMCSA has requested

funding for the registry and certification process, developed a statement of work, and

issued a request for proposals. Pending the establishment of the registry and certification

process, Safety Recommendation H-01-17 has been classified ìOpenñAcceptable

Response.î

Appendix C
63 Special Investigation Report

H-01-21

The review process prevents, or identifies and corrects, the

inappropriate issuance of medical certification.

In its April 11, 2002, letter to the Safety Board, the FMCSA responded to this

recommendation by stating that Section 215 of the Motor Carrier Safety Improvement Act

of 1999 (Public Law 106-l59, 113 Stat. 1748 [December 9, 1999]) requires that medical

certification be part of the commercial driverís license. FMCSA said that it believed that

the upcoming notice of proposed rulemaking (NPRM) to implement this provision, which

is expected to be published in the Federal Register by the early 2005, would address the

Safety Boardís concerns about the inappropriate issuance of a medical certificate. Pending

the publication of the NPRM addressing this issue, Safety Recommendation H-01-21 has

been classified ìOpenóAcceptable Response.î

H-01-22 

Enforcement authorities can identify invalid medical certification during

safety inspections and routine stops. 

H-01-23

Enforcement authorities can prevent an uncertified driver from driving

until an appropriate medical examination takes place. 

In its April 11, 2002, letter to the Safety Board, the FMCSA responded that

Section 215 of the Motor Carrier Safety Improvement Act of 1999 (Public Law 106-159,

113 Stat. 1748 [December 9, 1999]) requires that medical certification be part of the

commercial driverís license. The FMCSA further stated its belief that the upcoming

NPRM to implement this provision, at that time an internal draft document, would address

the Safety Boardís concerns about identifying invalid medical certificates with regard to

commercial driverís license (CDL) holders. By making the medical certification part of

the CDL, enforcement of the medical certification requirement at the roadside would no

longer be necessary for drivers who were required to have a CDL. On September 26,

2002, the Safety Board responded that, pending the publication of the NPRM addressing

these issues, Safety Recommendations H-01-22 and -23 have been classified ìOpenó

Acceptable Response.î

H-01-24

Mechanisms for reporting medical conditions to the medical certification

and reviewing authority and for evaluating these conditions between

medical certification exams are in place; individuals, healthcare providers,

and employers are aware of these mechanisms.

In the April 11, 2002, letter to the Safety Board, the FMCSA responded that the

June 1997 report, Update of Medical Review Practices and Procedures in U.S. and

Canadian Commercial Driver Licensing Programs, published by the Association for the

Advancement of Automotive Medicine, noted that all but nine States had the authority to

Appendix C
64 Special Investigation Report

suspend or revoke a commercial driverís license if they became aware between license

renewals that the driver is unable to meet the medical requirement. In addition, Section

215 of the Motor Carrier Safety Improvement Act of 1999 (Public Law 106-159, 113 Stat.

1748 [December 9,1999]) requires that medical certification be part of the commercial

driverís license. FMCSA believed that the upcoming NPRM to implement this provision,

at that time an internal draft document, would address the Safety Boardís concerns

regarding the need for a mechanism for reporting medical conditions to a reviewing

authority. 

On September 26, 2002, the Safety Board responded that it was aware that many

States have the authority to suspend or revoke a license if a driver cannot meet medical

standards. The Board noted further that, although the FMCSAís efforts are admirable, the

recommendationís intent is to ensure that information is provided to appropriate

authorities so that a decision can be made regarding continued licensure. The Safety Board

further stated that it is unclear what effect, if any, merging the medical certificate and CDL

would have on improving awareness among individuals, healthcare providers, and

employers of mechanisms of reporting conditions between medical certification

examinations that may impair driversí ability to safely operate a commercial motor

vehicle. Pending action by the FMCSA to improve the reporting and evaluation of medical

conditions between medical certification examinations, Safety Recommendation H-01-24

has been classified ìOpenóUnacceptable Response.î

In an August 31, 2004, letter to the Safety Board, the FMCSA stated that it plans to

establish a certification process and national registry for qualified medical practitioners.

According to the FMCSA, a certification program would ensure that medical practitioners

are qualified and educated about commercial driver occupational issues and have specific

guidance and a readily identifiable source of information for questions concerning the

physical examinations. The registry would allow the FMCSA and State licensing agencies

to better monitor practitioners on the registry, and it would provide a means to disseminate

information to practitioners regarding new medical discoveries, policies, or requirements

relevant to the examinations. 

The FMCSA also informed the Safety Board that it was establishing a nationally

recognized expert medical review board to make recommendations for revising medical

standards and recommendations for commercial motor vehicle drivers. The medical

review boardís duties will include researching requirements to enable the timely

development of future medical standards, interpreting medical research to support

regulatory and policy development, and providing the FMCSA with an authoritative

resource of medical expertise for making decisions on commercial driver medical and

physical qualifications. Although the FMCSA has yet to receive funding from Congress to

establish a certification process, a medical practitioner registry, and a medical review

board, it has already developed statements of work and has issued requests for proposals.

The Safety Board is evaluating the classifications for Safety Recommendations

H-01-17 through -24 in light of the FMCSAís latest response.

Appendix C
65 Special Investigation Report

American Association of Motor Vehicle Administrators (AAMVA)

The Safety Board issued Safety Recommendation H-01-26 to the AAMVA to urge

its member States to develop a comprehensive medical oversight program for intrastate

commercial drivers containing the same eight elements listed in Safety Recommendations

H-01-17 through H-01-24 to the FMSCA (see above). The AAMVA responded on

September 7, 2004, that it had worked closely with the FMCSA on rulemaking and that

once it is published, the AAMVA would use it as a basis for an intrastate medical

oversight program. Safety Board Recommendation H-01-26 is awaiting reclassification

that would reflect the latest correspondence from AAMVA.

National Conference of State Legislatures (NCSL)

H-01-27

Inform State legislatures about this accident and make them aware of the

importance of establishing immunity laws for the good-faith reporting of

potentially impaired commercial drivers by all individuals and of ensuring

that the medical community and the commercial transportation industry are

familiar with these laws. 

On September 7, 2001, the NCSL published an article on its Internet publication,

Transportation Notes, highlighting the Safety Boardís recommendations. Accordingly,

Safety Recommendation H-01-27 has been classified ìClosedóAcceptable Action.î

Appendix C
66 Special Investigation Report

Appendix D

Safety Board Public Hearing Agenda

NATIONAL TRANSPORTATION SAFETY BOARD

PUBLIC HEARING ON THE MEDICAL OVERSIGHT OF NONCOMMERCIAL 

DRIVERS

LíEnfant Plaza

WASHINGTON, D.C. 20594

March 18-19, 2003

PURPOSE: To investigate the current state of noncommercial driver medical

oversight, in support of a Safety Board investigation into a fatal multiple vehicle

crash that occurred in Hagerstown, Maryland, on November 3, 2002.

Tuesday, March 18, 2003

8:00ñ8:30 OPENING REMARKS

Member John Goglia Chairman, Board of Inquiry

8:30ñ8:45 INTRODUCTIONS AND TOPIC OVERVIEW

Rafael Marshall Hearing Officer

Mr. Ken Suydam Investigator-In-Charge

8:45ñ10:45 BACKGROUND AND RESEARCH

Background and research into potentially impairing or debilitating 

medical conditions that might affect an individualís ability to drive.

Dr. Richard Marotolli Connecticut Veterans Administration

Dr. Bonnie Dobbs University of Alberta

Dr. Dana Clarke Utah Diabetes Center

Dr. Allan Krumholz Maryland Epilepsy Center
67 Special Investigation Report

10:45ñ11:00 BREAK

11:00ñ1:00 REPORTING MEDICAL CONDITIONS

The role of various parties in collecting and routing information on 

medically high-risk drivers to licensing authorities and the medical 

review board. 

Dr. Laurel Broadhurst Weaverville Family Medicine

Mr. Rich Wiederhold Brevard County Public Safety 

Department

Sgt. Robert Ticer Arizona Highway Patrol

1:00ñ2:15 LUNCH

2:15ñ3:30 STATE OVERSIGHT

The effectiveness of State oversight of licensed drivers who suffer 

from potentially impairing or debilitating medical conditions.

Dr. Robert Raleigh Maryland Medical Advisory Board

Mr. Kurt Stromberg Utah Medical Advisory Board

Ms. Susan Stewart North Carolina Medical Advisory 

Board

3:30ñ3:45 BREAK

3:45ñ5:00 STATE OVERSIGHT (continued)

Wednesday, March 19, 2003

8:00ñ9:45 AWARENESS AND TRAINING

Programs that aid doctors, law enforcement, licensing authorities, 

and others report, manage, or counsel medically high-risk drivers.

Dr. Claire Wang American Medical Association

Sgt. Robert Ticer Arizona Highway Patrol

Ms. Jill Reeve Wisconsin Department of Motor 

Vehicles

Appendix D
68 Special Investigation Report

9:45ñ10:00 BREAK

10:00ñ12:00 NON-REGULATORY EFFORTS

Programs that attempt to reduce incidences of medically related 

accidents through education and other proactive measures.

Ms. Mary Jane OíGara AARP

Ms. Alexandra Finucane Epilepsy Foundation of America

Mr. Rex Knowlton Wheels of Wellness

Mr. Timothy Hoyt Nationwide Insurance

12:00ñ1:30 LUNCH

1:30ñ3:00 PUBLIC POLICY

Considerations in the design and implementation of a driver medical 

oversight program.

Dr. Richard Compton National Highway Traffic Safety

Administration

Mr. Mike Calvin American Association of Motor 

Vehicle Administrators

Mr. James Reed National Conference of State 

Legislatures

3:00ñ3:15 BREAK

3:15ñ4:45 PUBLIC POLICY (continued)

4:45ñ5:00 CLOSING REMARKS

5:00 END OF HEARING

Appendix D
69 Special Investigation Report

Appendix E

Laws of States With Mandatory Physician Reporting

Six States currently require physicians to report certain types of impairments to the

State licensing agency. The table below provides a summary of the medical impairments

specified in the laws of each of these six States and is followed by the reporting laws for

each State. 

Summary of State Mandatory Reporting Laws

States Medical Impairments Under Mandatory Physician Reporting

California Lapses of consciousness and Alzheimerís Disease severe enough to be likely to impair 

a personís ability to operate a motor vehicle

Delaware Loss of consciousness due to diseases of the central nervous system 

Nevada Epilepsy

New Jersey Recurrent convulsive seizures, recurrent periods of unconsciousness, or recurrent 

impairment or loss of motor coordination due to conditions such as epilepsy

Oregon Loss of consciousness or control. Cognitive and functional impairments that are severe 

and/or uncontrollable to a degree that may preclude safe operation of a motor vehicle 

and are not correctable by medication, therapy, surgery, driving device, or technique

Pennsylvania Lapses of consciousness or other mental or physical disabilities affecting the ability of a 

person to drive safely 
70 Special Investigation Report

California

Health and Safety Code

103900. Reporting Disorders Characterized by Lapses of Consciousness

(a) Every physician and surgeon shall report immediately to the local health officer in 

writing, the name, date of birth, and address of every patient at least 14 years of age or 

older whom the physician and surgeon has diagnosed as having a case of a disorder 

characterized by lapses of consciousness. However, if a physician and surgeon reasonably and in good faith believe that the reporting of a patient will serve the public interest, he or she may report a patientís condition even if it may not be required under the 

departmentís definition of disorders characterized by lapses of consciousness pursuant 

to subdivision (d). 

(b) The local health officer shall report in writing to the Department of Motor Vehicles the 

name, age, and address, of every person reported to it as a case of a disorder characterized by lapses of consciousness. 

(c) These reports shall be for the information of the Department of Motor Vehicles in 

enforcing the Vehicle Code, and shall be kept confidential and used solely for the purpose of determining the eligibility of any person to operate a motor vehicle on the 

highways of this state. 

(d) The department, in cooperation with the Department of Motor Vehicles, shall define 

disorders characterized by lapses of consciousness based upon existing clinical standards for that definition for purposes of this section and shall include Alzheimerís disease and those related disorders that are severe enough to be likely to impair a personís 

ability to operate a motor vehicle in the definition. The department, in cooperation 

with the Department of Motor Vehicles, shall list those circumstances that shall not 

require reporting pursuant to subdivision (a) because the patient is unable to ever operate a motor vehicle or is otherwise unlikely to represent a danger that requires reporting. 

The department shall consult with professional medical organizations whose members 

have specific expertise in the diagnosis and treatment of those disorders in the development of the definition of what constitutes a disorder characterized by lapses of consciousness as well as definitions of functional severity to guide reporting so that 

diagnosed cases reported pursuant to this section are only those where there is reason to 

believe that the patientsí conditions are likely to impair their ability to operate a motor 

vehicle. The department shall complete the definition on or before January 1, 1992. 

(e) The Department of Motor Vehicles shall, in consultation with the professional medical 

organizations specified in subdivision (d), develop guidelines designed to enhance the 

monitoring of patients affected with disorders specified in this section in order to assist 

with the patientsí compliance with restrictions imposed by the Department of Motor 

Vehicles on the patientsí licenses to operate a motor vehicle. The guidelines shall be 

completed on or before January 1, 1992. 

(f) A physician and surgeon who reports a patient diagnosed as a case of a disorder characterized by lapses of consciousness pursuant to this section shall not be civilly or criminally liable to any patient for making any report required or authorized by this section. 

Appendix E
71 Special Investigation Report

Delaware

TITLE 24

Professions and Occupations

CHAPTER 17. MEDICAL PRACTICES ACT

Subchapter VI. General Provisions

ß 1763. Reports of persons who are subject to losses of consciousness; limitation on

use; failure; penalty.

Every physician attending or treating persons who are subject to losses of consciousness

due to disease of the central nervous system shall report within 1 week to the Division of

Motor Vehicles the names, ages and addresses of all such persons unless such personís

infirmity is under sufficient control to permit the person to operate a motor vehicle with

safety to person and property.

The reports shall be for the information of the Division of Motor Vehicles in enforcing the 

Motor Vehicle Law. Said reports shall be kept confidential and used solely for the purpose 

of determining the eligibility of any person to operate a motor vehicle on the highways of 

this State.

A physician failing to make such a report shall be fined not less than $5 nor more than $50

and costs for each such report the physician fails to make. (24 Del. C. 1953, ß 1763; 50

Del. Laws, c. 369, ß 1; 70 Del. Laws, c. 186, ß 1; 71 Del. Laws, c. 451, ßß 1, 2.)

Appendix E
72 Special Investigation Report

Nevada

Nevada Revised Statutes

CHAPTER 439

Administration of Public Health and General Provisions

NRS 439.270 Persons diagnosed with epilepsy:

State Board of Health to define ìepilepsyî for purposes of section; reports required to be

submitted to Health Division and to Department of Motor Vehicles; confidentiality of

reports; criminal penalty.

1. The State Board of Health shall define epilepsy for the purposes of the reports 

hereinafter referred to in this section.

2. All physicians shall report immediately to the Health Division, in writing, the name,

age and address of every person diagnosed as a case of epilepsy.

3. The Health Division shall report, in writing, to the Department of Motor Vehicles the

name, age and address of every person reported to it as a case of epilepsy.

4. The reports are for the information of the Department of Motor Vehicles and must be

kept confidential and used solely to determine the eligibility of any person to operate a

vehicle on the streets and highways of this state.

5. A violation of this section is a misdemeanor.

Appendix E
73 Special Investigation Report

New Jersey

TITLE 39

 MOTOR VEHICLES AND TRAFFIC REGULATION

39:3-10.4. Report to director by physicians of persons subject to epileptiform 

seizures

Each physician treating any person 16 years of age or older for recurrent convulsive 

seizures or for recurrent periods of unconsciousness or for impairment or loss of motor 

coordination due to conditions such as, but not limited to, epilepsy in any of its forms, 

when such conditions persist or recur despite medical treatments, shall, within 24 hours 

after his determination of such fact, report the same to the Director of the Division of 

Motor Vehicles. The director, in consultation with the State Commissioner of Health, shall 

prescribe and furnish the forms on which such reports shall be made.

L.1970, c. 195, s. 1, eff. Sept. 4, 1970.

Appendix E
74 Special Investigation Report

Oregon

Oregon Revised Statutes - 2003 Edition

Chapter 807 ó Driving Privileges, Licenses and Permits

807.710 Reports of persons with cognitive or functional impairment; rules; forms.

(1) For the purposes of this section:

(a) ìPhysicianî means a doctor of medicine or osteopathy licensed to practice 

medicine by the Board of Medical Examiners for the State of Oregon.

(b) ìHealthcare providerî means a person licensed, certified or otherwise authorized 

or permitted by the laws of this state to administer healthcare .

(2) In consultation with medical experts and experts on cognitive or functional 

impairments, the Department of Transportation shall adopt rules requiring 

reporting and:

(a) Designating physicians and healthcare providers required to report to the 

department a person whose cognitive or functional impairment affects that 

personís ability to safely operate a motor vehicle. If a designated physician or 

healthcare provider makes a report to the department in good faith, that person 

shall be immune from civil liability that might otherwise result from making the 

report. If a designated physician or healthcare provider does not make a report, 

that person shall be immune from civil liability that might otherwise result from 

not making the report.

(b) Designating the cognitive or functional impairments that are likely to affect a 

personís ability to safely operate a motor vehicle.

(3) Determinations regarding a personís ability to safely operate a motor vehicle may not 

be based solely on the diagnosis of a medical condition or cognitive or functional 

impairment, but must be based on the actual effect of that condition or impairment 

on the personís ability to safely operate a motor vehicle.

(4) Reports required by the department under this section shall be upon forms prescribed 

or provided by the department. Each report shall include the personís name, 

address, date of birth, sex and a description of how the personís current medical 

status affects the personís ability to safely operate a motor vehicle. The State 

Health Officer shall consider this information in determining whether to issue a 

certificate of eligibility under ORS 807.090.

(5) Except as provided in ORS 802.240, the reports required by the department under this 

section are confidential and shall be used by the department only to determine the 

qualifications of persons to operate motor vehicles upon the highways. [1983 

c.338 ß872; 1999 c.770 ß2; 2001 c.736 ß1; 2003 c.462 ß1]

Note: Section 3, chapter 462, Oregon Laws 2003, provides:

Sec. 3. The amendments to ORS 807.710 and 802.240 by sections 1 and 2 of this 2003 Act

apply only to causes of action that accrue on or after the effective date of this 2003 Act

[June 24, 2003]. [2003 c.462 ß3]

Appendix E
75 Special Investigation Report

Pennsylvania

Pennsylvania Consolidated Statutes

THE VEHICLE CODE (Title 75)

Part II. Title, Registration and Licensing

CHAPTER 15. LICENSING OF DRIVERS

ß 1518. Reports On Mental Or Physical Disabilities Or Disorders.

(a) Definition of disorders and disabilities. The Medical Advisory Board shall define disorders characterized by lapses of consciousness or other mental or physical disabilities 

affecting the ability of a person to drive safely for the purpose of the reports required 

by this section.

(b) Reports by medical personnel. All physicians and other persons authorized to 

diagnose or treat disorders and disabilities defined by the Medical Advisory Board 

shall report to the department, in writing, the full name, date of birth and address of 

every person over 15 years of age diagnosed as having any specified disorder or 

disability within ten days.

(c) Responsibility of institution heads. The person in charge of every mental hospital, 

institution or clinic, or any alcohol or drug treatment facility, shall be responsible to 

assure that reports are filed in accordance with subsection (b).

(d) Confidentiality of reports. The reports required by this section shall be confidential and

shall be used solely for the purpose of determining the qualifications of any person to

drive a motor vehicle on the highways of this Commonwealth.

(e) Use of report as evidence. No report forwarded under the provisions of this section 

shall be used as evidence in any civil or criminal trial except in any proceeding under 

section 1519(c) (relating to determination of incompetence).

(f) Immunity from civil and criminal liability. No civil or criminal action may be brought 

against any person or agency for providing the information required under this system.

Appendix E
76 Special Investigation Report

Appendix F

State Immunity Laws

Ability of States to Offer Immunity to Individuals Reporting 

Concerns About Driver Fitness.1 

1 Data from Federal Highway Administration, Update of Medical Review Practices and Procedures in

U.S. and Canadian Commercial Driver Licensing Programs, Report PB97-194393INZ, (Washington, DC:

FHWA, 1997); K.H. Lococo, Summary of Medical Advisory Board Practices in the United States, prepared

for the National Highway Traffic Safety Administration by Transanalytics, contract #DTNH22-02-P-0511

(2003).

State Immunity to persons who in good 

faith report an unfit driver

Immunity to physicians who 

report an unfit driver

Alabama Yes Yes

Alaska Yes No

Arizona No Yes

Arkansas No No

California No Yes

Colorado Yes Yes

Connecticut Yes Yes

Delaware No Yes

District of 

Columbia

No No

Floridaa Yes Yes

Georgia Yes Yes

Hawaii No No

Idaho No No

Illinois Yes Yes
77 Special Investigation Report

State Immunity to persons who in good 

faith report an unfit driver

Immunity to physicians who 

report an unfit driver

Indiana No No

Iowa No Yes

Kansas Yes Yes

Kentucky Yes Yes

Louisiana No Yes

Maine Yes Yes

Maryland Yes Yes

Massachusetts No No

Michigan No No

Minnesota No Yes

Mississippi N/A No

Missouri No Yes

Montanab Yes Yes

Nebraska No No

Nevada N/A Yes

New Hampshire N/A No

New Jersey No Yes

New Mexico No Yes

New York Yes No

North Carolina No Yes

North Dakota No Yes

Ohio No No

Oklahoma Yes Yes

Oregon No Yes

Appendix F
78 Special Investigation Report

State Immunity to persons who in good 

faith report an unfit driver

Immunity to physicians who 

report an unfit driver

Pennsylvania Yes Yes

Rhode Island No Yes

South Carolina N/A No

South Dakota No No

Tennessee No No

Texas No Yes

Utah Yes Yes

Vermont No No

Virginia N/A Yes

Washington No No

West Virginia No No

Wisconsin No Yes

Wyoming Yes Yes

a.<http://www.hsmv.state.fl.us/forms/72190.html>.

b.<http://data.opi.state.mt.us/bills/mca/37/2/37-2-312.htm>.

Appendix F
79 Special Investigation Report

Appendix G

State Oversight Procedures of Four Representative States

Pennsylvania

In Pennsylvania, all learnerís permit applicants must undergo a physical exam by a

medical provider and must have the provider complete a section on the back of the

learnerís permit application relating to medical conditions. The Pennsylvania Department

of Transportation (PennDOT) may require further medical examinations if a physician

indicates that the applicant has any of the following disorders: neurological, cardiac or

circulatory, neuropsychiatric, conditions causing repeated lapses of consciousness,

alcoholism, narcotic addiction, uncontrolled diabetes, uncontrolled epilepsy, immobility

or amputation of an appendage, or any other condition that might adversely affect the

operation of a motor vehicle.1

New residents applying for a driverís license in Pennsylvania are also required to

complete a section in their applications regarding their medical history. Among other

conditions, the application asks whether the applicant suffers from neurological disorders,

cardiac or circulatory disorders, or neuropsychiatric disorders that might prevent the

reasonable control of a motor vehicle. It also asks whether the applicant has a condition that

may result in repeated lapses of consciousness, such as epilepsy, narcolepsy, or hysteria.

Individuals renewing their licenses may do so in person, by mail, or by Internet,

and are not required to provide medical history information during that time. According to

the Manager of the Driver Qualification Section of PennDOT, the State has no laws that

require driverís license holders to inform PennDOT if they develop a potentially impairing

medical condition.2

In addition to self-reports, PennDOT accepts reports on medically high-risk

drivers from law enforcement officials, physicians, family members, friends, and other

citizens. It does not accept anonymous reports. Physicians, and other persons authorized to

diagnose or treat disorders, are required by Pennsylvania law to report individuals, age 15

or older, having one of the disorders listed in the first paragraph of this section. Immunity

from civil and criminal liability is given to any person or agency providing information on

a driver with a potentially impairing or debilitating medical condition.

PennDOT receives approximately 16,000 initial reports a year from the medical

community on licensed Pennsylvania drivers who may be too medically impaired to drive

1 Title 75, Part II, Chapter 15, Section 1518 of the Pennsylvania Consolidated Statutes.

2 Telephone interview, November 7, 2003.
80 Special Investigation Report

safely.3 Approximately 20 percent of reported drivers are found to have a condition

serious enough to warrant a license suspension or revocation. About half of those whose

licenses are suspended or revoked for medical reasons are drivers with seizure disorders,

with another 16 percent suffering from neurological disorders. Another 25 percent of the

16,000 initial reports result in license suspensions because those drivers do not comply

with PennDOTís requests for further medical information. 

To assist healthcare providers, PennDOT makes available a ìPhysician Reporting

Fact Sheetî and provides an initial reporting form. PennDOT last mailed the fact sheet in

2001 to all physicians licensed in Pennsylvania. PennDOT also periodically schedules

presentations at hospitals for physicians and medical students on its reporting requirements.4

PennDOT also receives about 2,500 police and crash reports annually, which

potentially involve medically high-risk drivers. Pennsylvania accident reporting forms

used by law enforcement include a field that inquires about a driverís condition at the time

of the crash, including whether the driver has a preexisting physical defect, some other

handicap, or was ill, intoxicated, or fatigued. PennDOT receives another 500 referrals

from driver acquaintances annually. 

In regard to the Hagerstown accident, which involved a driver with a Pennsylvania

license, PennDOT5

 stated that no laws or formal agreements exist between States to share

information about medically related traffic stops or incidents that involve an out-of-State

driver. However, PennDOT occasionally receives such information from other States

regarding drivers licensed in Pennsylvania. 

The PennDOT Medical Unit reviews the medical reports that are sent to the

agency. Because Medical Unit staff are not healthcare professionals (nurses or

physicians), they receive 9 to 12 months of training on medical terms, Pennsylvania law,

department regulations, and the computer system used to evaluate and track drivers and

applicants before being allowed to review the medical reports submitted to PennDOT. 

When the Medical Unit receives a report on a driver from a physician, staff

members compare the report information to PennDOTís statutes and standards.6

 The

Medical Unit may recall or restrict a driverís license based solely on a physicianís report

or it may require the driver to undergo further vision or medical exams. If more medical

information is required, the Medical Unit will send a condition-specific medical form (eye

report, neurological form, or cardiovascular form) to the driver, who must then undergo

the specific medical exam by a physician of his or her choice, have the physician complete

the form, and then submit it to PennDOT within 30 days. If the driver does not submit the

3 The PennDOT states that it receives over 40,000 reports each year from the medical community

regarding drivers with medical conditions. However, according to the manager of PennDOTís Driver

Qualification Section, this number reflects both initial and followup reports on high-risk drivers.

4 Telephone interview, Manager, Driver Qualification Section, PennDOT, November 7, 2003.

5 Telephone interview, Manager, Driver Qualification Section, PennDOT, July 9, 2003. 

6 K.H. Lococo, Summary of Medical Advisory Board Practices in the United States, prepared for the

National Highway Traffic Safety Administration by Transanalytics, contract DTNH22-02-P-0511 (2003).

Appendix G
81 Special Investigation Report

completed form within the required timeframe, the license may be put on pending

suspension status for 30 additional days before it is fully suspended due to noncompliance.

Based on the information on the completed form, the Medical Unit may decide to clear the

driver, recall the license, or require the driver to take a road test.7 

When reports are received from nonmedical sources, a general medical form is

sent to the driver, requiring a physical examination. PennDOT will not automatically

recall a license based on information from a nonmedical source. The Medical Unit

frequently contacts the source of the report by telephone, especially for reports from

family members, to ask for more information or to discuss the case to determine validity.

When the report is from an acquaintance, additional precautions are taken. The Medical

Unit recognizes that while some reports that come from these individuals are made out of

legitimate concern, others could be the result of malice.

PennDOT is assisted in the medical evaluation of drivers by a 13-member Medical

Advisory Board. The Medical Advisory Board consists of eight physicians with

backgrounds in one or more of the following specialties: optometry, ophthalmology,

cardiology, family practice, internal medicine, neurology, orthopedics, and psychiatry. The

five other members include the Director of the Bureau of Driver Licensing, the PennDOT

chief counsel, and representatives from the Department of Health, the Advisory Council

on Drug and Alcohol Abuse, and the Pennsylvania State Police. The duties of the Medical

Advisory Board are to keep PennDOT informed of new fitness-to-drive research; advise

PennDOT on new driving regulations, procedures, and guidelines; assist in the

development of medical reporting forms; and, on rare occasions, provide guidance on

individual licensing cases.8

 Of the 16,000 initial reports submitted to the Medical Unit

each year, only about five cases are referred to the Medical Review Board for evaluation.9

Pennsylvaniaís standards regarding epilepsy are described in Title 67, Article IV,

Chapter 83, Section 83.4, of the Pennsylvania Code. It states that ìa person who has a

seizure disorder shall not be qualified to drive unless the person has been free from seizure

for a period of at least 6 months from the date of the last seizure, with or without

medication.î Individuals between the ages of 16 and 18 who are applying for a license for

the first time must have been free of seizures for at least 2 years. Waivers are considered

under various circumstancesóif seizures occur only at night or immediately after waking,

for example, or if a specific prolonged aura always occurs prior to a seizure. 

PennDOT provides booklets to the public describing the physiological changes

associated with aging, as well as a guide to help families cope with older drivers.

PennDOT does not provide counseling to individuals with a medical impairment that

hampers or precludes their ability to drive. It also does not refer individuals to outside

sources of counseling or rehabilitation.

7 Title 75, Part II, Chapter 15, Section 1519, Pennsylvania Consolidated Statutes.

8 Title 75, Part II, Chapter 15, Section 1517(b), Pennsylvania Consolidated Statutes.

9 Lococo (2003).

Appendix G
82 Special Investigation Report

Maryland 

 Physicians in Maryland are not legally required to report individuals 15 years of

age and older who have potentially impairing or incapacitating medical conditions,

although they may do so voluntarily. Drivers who are renewing10 or obtaining licenses for

the first time in Maryland are required to inform the Motor Vehicle Administration (MVA)

if they have one of 17 high-risk medical conditions11 listed on the license application form.

Drivers who indicate that they have one or more of these medical conditions or drivers

suspected by MVA license examiners of having a high-risk condition12 are referred to the

Driver Wellness and Safety Division, which houses the Stateís Medical Advisory Board

(MAB). Approximately 35 percent of all referrals in Maryland are through self-reporting

or license examiner referrals. Other referral sources include law enforcement (35 percent),

healthcare professionals (17 percent), private citizens (11 percent), and the court system.

Law enforcement officers refer drivers to the MAB by filling out a request for

reexamination. Physicians refer drivers via a letter to the MAB. The legitimacy of

referrals from friends, family, or from an anonymous source is validated by an MVA field

investigator before contacting a driver about a potential impairment.13 All reports are

confidential and may only be disclosed by court order. Physicians, and those who refer a

driver in good faith, are granted immunity from civil and criminal action.

Drivers referred to the MVA are mailed a Driver License Medical Assessment

Packet, which contains the Health Questionnaire, medical record release forms, and

physician reporting forms. The assessment packet may also contain a notification to

undergo a Functional Capacity Screening with a trained MVA Driver License Examiner.14

Drivers are asked to authorize the release of medical information to the MVA and forward

the physician report forms to their physicians for completion.15 The screening consists of

a battery of written and physical tests that are correlated to driving ability. 

Six Driver Wellness and Safety case managers are tasked with assembling the

medical information on each referred driver and forwarding that information to the MAB.

Six other case managers conduct a similar task exclusively for alcohol-related referrals.

All case managers are registered nurses. 

The MAB consists of 16 physicians whose specialties include preventive

medicine, ophthalmology, cardiology, family practice, internal medicine, neurology,

10 Driverís licenses are valid for 5 years and can be renewed only in person.

11 A list of these conditions is available at <http://mva.state.md.us/DriverServ/APPLY/apply.htm>.

12 Licensing Agency personnel are not formally trained to observe applicants for conditions that could

impair their ability to operate a motor vehicle safely.

13 Testimony of Dr. Carl Soderstrom, Associate Director of the Medical Advisory Board for the

Maryland Motor Vehicle Administration, NTSB hearing, Medical Oversight of Noncommercial Drivers,

March 18-19, 2003.

14 Driver License Examiners in a number of branches have been trained to do functional capacity

testing (in conjunction with the Maryland Pilot Study). 

15 If drivers do not return the packet or do not authorize the release of medical information, their

licenses are suspended until they comply.

Appendix G
83 Special Investigation Report

psychiatry, and general surgery. The MVA Administrator appoints physicians on the MAB

for a 3-year term. Each physician performs about 12 hours of casework a week. The MAB

does not meet as a group. An individual MAB member makes a decision on each referral. If

more information is required on a particular driver, a member may conduct a

videoconference or in-person interview with the driver and may ask for further medical

examination or a driving test. After completing its review, the MAB may recommend to the

MVA that a driverís license be denied, suspended, or restricted, or that no action be taken. 

During 2002, the Driver Wellness and Safety Division handled

approximately 13,700 cases. The Driver Wellness and Safety Division routinely maintains

a 5-year active caseload of approximately 42,000 cases. Once a case remains unchanged

for 5 years, the case is archived and considered closed. Each year, the MVA denies

licenses for more than 1,200 drivers because of existing medical conditions.

The MVA offers counseling and information on alternative transportation, safe

driving tips, and support groups to drivers whose licenses are denied, suspended, or

restricted. Drivers may appeal a decision to deny or restrict their licenses by requesting a

hearing before an administrative law judge. 

Regarding epilepsy, it should be noted that until October 1, 2003, Maryland statute

restricted the MAB from suspending the license of a driver with epilepsy for more than 90

days. For other medical impairments, the Board could recommend suspensions of varying

lengths. The new Maryland State law16 removes this restriction and allows the MAB to adopt

the more flexible approach on suspensions employed for other medical impairments, based

on a medical assessment of the clientís condition and his or her capacity to drive.

California

In California, the Department of Motor Vehicles (DMV) administers driver

licensure. Applicants who are renewing17 or obtaining licenses for the first time must

complete a section of the licensing application that contains questions about medical

conditions. Applicants are asked whether in the past 5 years, they have experienced (1) a

loss of consciousness, (2) an episode of marked confusion caused by any condition that

may bring about recurring lapses, (3) a disease, disorder, or disability (such as epilepsy,

diabetes, stroke, cataracts, or Parkinsonís disease), (4) a decrease or change in vision due

to cataracts, macular degeneration, or other progressive condition, or (5) health problems

due to alcohol or drug abuse. Applicants who self-report may be required to have a

physician complete a Driver Medical Evaluation form, which is used by the DMV to assist

in arriving at a licensing decision on the driver.

16 House Bill 685, Chapter 171 (<http://mlis.state.md.us/2003rs/billfile/HB0685.htm>).

17 Driverís licenses are valid for 5 years. Licenses can be renewed in person or by mail for no more than

2 license terms in sequence.

Appendix G
84 Special Investigation Report

License examiners at the DMV are trained to observe applicants for signs of

physical and cognitive impairment. Examiners assess applicants on their ability to use

their arms and legs, and for obvious and excessive shaking or stiffness in their upper and

lower limbs. Depending on the degree of impairment, a person who exhibits physical or

cognitive problems in any of these areas might be required to take a driving test, might

have the driverís license immediately suspended, or might be referred to the Driver Safety

Branch for reexamination.18 

In addition to self-reports and license examiner referrals, California also accepts

referrals from healthcare workers, law enforcement, the courts, family, friends, and other

citizens. California has a mandatory physician reporting law. Physicians must report

immediately to the health officer every patient age 14 and older who has been newly

diagnosed with a disorder characterized by lapses of consciousness, such as dementia,

seizure disorders, brain tumors, narcolepsy, sleep apnea, and abnormal metabolic states,

including hypo- and hyperglycemia associated with diabetes. Physicians who report

patients with disorders marked by lapses of consciousness are not civilly or criminally

liable to any patient for making such a report. Other possibly high-risk conditions may be

reported to the DMV, but there is no statutory immunity for voluntary reporting. If a

physician fails to report a patient with a condition that may cause lapses of consciousness,

and that patient is involved in a crash, the physician may be held liable.

Law enforcement officers who believe that a driver might have a high-risk medical

condition may refer a driver to the DMV for a ìregular reexaminationî or a ìpriority

reexamination.î Drivers who are referred for a regular reexamination may have their

driverís license immediately suspended or they may be asked to present medical

information and may be required to take a vision, knowledge, or driving test if appropriate.

If an officer observes a driver who has violated a traffic law and is clearly suffering from an

incapacitating medical condition, the officer can refer the driver for a ìpriority

reexamination.î Drivers who are referred for a priority reexamination must contact the

DMV within 5 days to schedule a reexamination or face a license suspension. These drivers

are instructed to bring another licensed driver to the reexamination, must provide medical

information, and must take the knowledge, vision, and driving tests. The DMV may

immediately suspend or revoke the driving privilege upon receipt and investigation of a

notice of priority reexamination. The California DMV conducts approximately 3,000

priority reexaminations and 36,220 regular reexaminations each year.19

Anonymous referrals are accepted from immediate family only. All others must

provide a signature. Individuals may report drivers by writing a letter or by using the

Request for Reexamination form, which provides check boxes to describe the driverís

condition and the driverís specific behaviors, in addition to space to write a narrative to

further describe conditions or actions. The Licensing Agency may contact a reporting

source before proceeding with a reevaluation of the driver.

18 Lococo, Summary of Medical Advisory Board Practices in the United States (2003). 

19 Susan Bradley, Manager III, Licensing and Operations Division, California Department of Motor

Vehicles, e-mail correspondence, November 11, 2003.

Appendix G
85 Special Investigation Report

Finally, the DMV will investigate any person who has been involved in a crash

causing death or who has been involved in three or more crashes within a 12-month

period, regardless of whether the accidents were medically related. If the driver is

reexamined, medical information may be requested, if appropriate, to determine whether a

condition contributed to the crashes. The length of time required for a reexamination may

vary, depending on whether medical information is needed to make a final decision. If the

evidence warrants, an immediate suspension can be taken within days.20 

California has an MAB, but it is currently inactive. The MAB is only reactivated

when revisions to the DMVís medical evaluation guidelines are necessary. MAB members

do not review individual cases. Nonmedical administrative personnel in the DMVís Driver

Safety Branch evaluate all medically related referrals. The staff, who may review these

medically related referrals, consists of 165 driver safety hearing officers, 62 driver safety

managers (former hearing officers with extensive experience), and 22 motor vehicle

technicians. Hearing safety officers undergo 3 weeks of training and are given a resource

book of ìPhysical and Mental Contactsî to help them evaluate referrals. Motor vehicle

technicians receive less training because they are not as involved in the driver evaluation

process. Driver Safety Branch personnel are also provided with regulatory guidelines on

which to base licensing decisions. 

Drivers who are referred to the DMV may be sent a Driver Medical Questionnaire

and a Driver Medical Evaluation form. The Driver Medical Questionnaire may be

completed by the driver and the Driver Medical Evaluation by a physician; both forms

must be returned to the DMV. The driverís case is assigned to a hearing officer, who

reviews the driverís medical information, driving record, and reexamination results. The

hearing officer then makes a final licensing decision. Driver safety managers and motor

vehicle technicians also review medical forms as part of their duties. 

Drivers who are found during reexamination to have a cognitive or physical

impairment are given the Supplemental Driver Performance Evaluation (SDPE). The

SDPE is also given to drivers who are referred for a ìpriority reexamination.î The SDPE

is an on-the-road test that is designed to evaluate a driverís cognitive and physical ability

to drive a motor vehicle safely. The cognitive skills that are tested include working

memory, spatial memory, and divided and selective attention. Drivers can also opt to take

the Area Driving Performance Evaluation (ADPE) test if they wish only to drive in a

restricted area, such as near home, the grocery store, or the doctorís office. The driver

must demonstrate that he or she can safely drive on all location trips. 

Drivers whose licenses have been suspended, restricted, or revoked for a medical

or functional impairment may appeal the decision by requesting a hearing. They may be

represented by an attorney, review and cross-examine DMV witnesses, present evidence

and relevant witnesses, or testify on their own behalf. Individuals who disagree with the

hearing officerís decision may request a departmental review of the decision and may

appeal the decision in superior court. The DMV currently does not provide counseling or

20 Susan Bradley, Manager III, Licensing and Operations Division, California Department of Motor

Vehicles, e-mail correspondence, November 11, 2003.

Appendix G
86 Special Investigation Report

information to drivers who have lost all or some of their driving privileges due to a medical

condition. However, as part of a pilot study, an educational package is being mailed to a

sample of older drivers who have had a traffic conviction or crash within the past 18 months.

The educational package includes information on medication and driving, collision

avoidance strategies, support groups, and California DMV requirements and procedures. 

Wisconsin

In Wisconsin, the Division of Motor Vehicles is in charge of driverís licenses.

Applicants renewing21 or obtaining their licenses for the first time are required to state

whether they have, in the past year, experienced a loss of consciousness or muscle control

caused by any of the following conditions: a brain or head injury, diabetes, stroke, seizure

disorder, mental disorder, muscle or nerve disorder, or heart or lung ailment. Applicants

who self-report a medical impairment must have their physicians complete a medical

examination report and return the report to the DMV within 30 days.

License examiners are formally trained to use information gathered from inquiries

into an applicantís functional ability to drive, information from a completed license

application form, information from a previous driving record, and observations of motor

and cognitive ability.22 Applicants who do not meet the standards detailed in the Driver

Licensing Manual may be required to undergo a driving skills test or evaluation, file a

medical report, or both.

23

The Wisconsin DMV also accepts referrals from healthcare personnel, law

enforcement officials, private citizens, and the courts. Over 60 percent of all referrals are

from law enforcement officials, and about 10 percent are from physicians.24 Wisconsin

does not have a mandatory physician reporting law, but physicians are encouraged to

report unsafe drivers. As mentioned previously, the Wisconsin DMV mails brochures on

its reporting laws yearly to physicians in the State to keep them informed. Physicians who

report drivers in good faith are immune from legal action by their patients. Law

enforcement officials and private citizens can refer a potentially impaired driver to the

DMV by filling out a ìDriver Condition or Behavior Report.î The DMV investigates all

21 Driverís licenses are valid for 8 years. Licenses must be renewed in person, but can be renewed by

mail if the applicant is temporarily out of the State.

22 Examiners undergo 8 weeks of off-site classroom training for all licensing functions, in addition to

on-the-job training, where they are on probation for the first year of service. The 8 hours of classroom

training include medical conditions and physical functionality, based on Wisconsinís Driver Licensing

Manual, Section 235, ìEvaluating Medical Conditions or Disabilities.î Specialized training is also provided

to licensing personnel relating to older drivers.

23 Section 235, ìEvaluating Medical Conditions or Disabilities,î of the Driver Licensing Manual details

the functional standards that drivers must meet to obtain an unrestricted license in Wisconsin.

24 Testimony of Ms. Jill Reeves, Program Supervisor for the Medical Review Unit of the

Wisconsin Department of Transportation, NTSB hearing, Medical Oversight of Noncommercial Drivers,

March 18-19, 2003.

Appendix G
87 Special Investigation Report

reports received from private citizens to ensure that the referral was submitted in good

cause and not with malicious intent. 

When drivers are referred to the Wisconsin DMV via the Driver Condition or

Behavior Report, they are sent a packet that contains the Medical Examination Report, to

be completed by a physician. The Medical Examination Report inquires about a driverís

condition, symptoms, treatment, medication, mental state, and psychomotor skills. It also

asks whether the driverís skills should be retested or whether license privileges should be

restricted or suspended/revoked. 

Completed Driver Condition or Behavior Reports are sent to the Medical Review

Section of the DMV, which usually acts upon the recommendations of the physician. The

Medical Review Section, staffed by eight transportation customer service representatives25

and one full-time registered nurse, processes over 38,000 reports a year.

If the Medical Review Section determines that a driver reexamination is needed, the

driver is contacted to schedule a vision test, knowledge test, and a road test. The tests must be

completed within 60 days, or the driverís license will be revoked. Road tests are examinerdirected and can be modified to evaluate a specific impairment. Particular attention is given to

a driverís range of motion, reaction time, endurance, coordination, speed in operating/moving

controls, strength inoperating controls, ability to cope with traffic, alertness, and ability to

turn the head and body. Drivers who fail any part of the reexamination may take it again, but

must surrender their licenses if they do not pass on the second attempt. Drivers may be given

a limited-area driving test if a restricted license is requested. 

Drivers whose driving privilege is curtailed or denied by the DMV may appeal the

decision to the Wisconsin MRB. The MRB is comprised of 152 physicians who are

volunteer consultants to the DMV. The medical specialties represented by MRB members

include optometry, ophthalmology, cardiology, family practice, internal medicine,

neurology, psychiatry, endocrinology, and psychiatry. All MRB members are volunteers who

serve terms at their discretion. Members are immune from legal action, and their identities

are anonymous. MRB records and deliberations are confidential although they may be

admitted as evidence in judicial review proceedings of drivers who choose to appeal. 

A portion of the Wisconsin MRB meets on a voluntary basis each month to discuss

appeals. These meetings include three MRB members26 and a DOT representative. The

appealing driver may appear in person before the MRB or request a review by mail. The

Medical Review Section takes into account recommendations of the MRB but is still

responsible for the final licensing decision. In 2002, the Board reviewed 398 cases, of

which 225 drivers were denied a license following review. Drivers who wish to appeal

their cases further may ask for a judicial review.

25 Transportation customer service representatives are nonmedical administrative staff, formally trained

in driver medical standards and dedicated to medical review activities.

26 Volunteers must be from one of the following disciplines: internal medicine, neurology, or psychiatry.

Appendix G
88 Special Investigation Report

Wisconsin does provide counseling and information for drivers with functional

impairments that limit or preclude driving privileges. A nurse consultant counsels drivers

and caretakers on crises related to license denials or restrictions, explains the importance

of health and driving, directs citizens to advocacy groups, and provides information about

alternative transportation options.

Appendix G
89 Special Investigation Report

Appendix H

American Automobile Association Basic Best Practices for 

Medical Advisory/Review Boards1

1. Every State should have a Medical Advisory Board/Medical Review Board.

2. The Medical Advisory Board should consist of physicians as well as other

healthcare professionals. These professionals may include, but are not limited

to: Occupational Therapists, Nurses, Gerontologists, and Physicians of diverse

specialties.

3. The Medical Advisory Board should meet in person or by teleconference to

advise on the Stateís medical review program.

4. The Medical Advisory Board should review cases to assist the Department of

Motor Vehicles (DMV) in making an initial determination of fitness to drive

for individuals who come to the attention of the medical review department as

being potentially at risk (especially complex cases where administrative

review is insufficient). 

5. The Medical Advisory Board should have authority to recommend

customized/restricted licenses to allow driving privileges under safe conditions

(that is, daytime, speed restricted, or area restricted) when possible, instead of

just revoking licenses altogether. 

6. The Medical Advisory Board should have the authority to recommend periodic

medical reexaminations and/or periodic road tests of drivers as needed, to

ensure that a driver with a progressive medical condition has the capability to

continue to drive safely.

7. Physicians and other professionals on the Medical Advisory Board should be

financially compensated, rather than serving on a volunteer basis. (Ideally,

physicians should be employed as DMV staff, but where this is not possible,

Board members should be paid as consultants and compensated according to

accepted hourly rates for the profession.)

8. Board members should be immune from liability from the individuals for

whom they make licensing recommendations, and all healthcare professionals

who report drivers in good faith should be immune from liability from their

patients. 

1 These recommendations were developed in consultation with experts and following review of the

Summary of Medical Advisory Board Practices based on the National Highway Traffic Safety

Administration (NHTSA) and American Association of Motor Vehicle Administrators (AAMVA) survey of

licensing agencies in the United States. NHTSA and AAMVA will publish the comprehensive report in fall

2004. Consult <http://www.aamva.org/drivers/drvProblemDriversMedicalAdvisoryBoardPractices.asp>.
90 Special Investigation Report

9. Individual Board members should be able to review cases and make licensing

recommendations (so that a Board member with the required expertise can

make the decision) as opposed to requiring consensus by a panel of Board

members (requiring a panel for all cases is less efficient and more costly). A

panel of Board members can be utilized for more complex cases.

10. The Medical Advisory Board should develop medical guidelines for licensing

in the State. (Ideally, States should work with health professionals to develop

national medical guidelines using the American Medical Association (AMA)

Physicianís Guide for Assessing and Counseling Older Drivers as a starting

point.)2

2 AAMVA has a 3-year cooperative agreement project with NHTSA to develop recommended national

medical guidelines. States and medical professionals will work together to produce guidelines that are

medically sound, uniform and feasible for States to implement.

Appendix H
91 Special Investigation Report

Appendix I

United We Ride Initiative

The table below describes the five components of the ìUnited We Rideî initiative

and their relation to the coordination options in U.S. Government Accountability Office

(GAO) June 2003 report.

Source: GAO analysis of information from the Department of Transportation, the Department of Health and Human 

Services, the Department of Labor, the Department of Education, the American Association of Retired Persons, the 

Community Transportation Association of America, and the National Council for Independent Living.

Component Description

Related

Coordination Options

Framework for Action A tool States and communities can use 

to assess their coordination efforts and 

identify areas for improvement.

Provides additional 

coordination guidance to 

States and communities.

State Leadership Awards Awards to recognize three to five States 

that have made significant progress in 

coordination; awards are to be 

presented at National Leadership 

Forum.

Recognizes successful State 

leadership efforts and 

encourages other States to 

coordinate.

National Leadership 

Forum on Human 

Services Transportation 

Coordination

Transportation and human service 

teams from each State were invited to 

participate in the February 2004 

conference to highlight coordination 

successes, technical assistance 

programs, and peer advice.

Provides opportunities to 

demonstrate Federal and 

State leadership in 

coordination.

Provides forum for 

interagency communication.

State Coordination Grants Grants to address transportation 

coordination gaps and needs identified 

through the Framework for Action; 

States participating in the Forum are 

eligible to apply.

Provides financial incentives 

to encourage States to 

coordinate.

Help Along the Way Technical assistance program; Federal 

departments and national organizations 

are working to coordinate existing 

technical assistance services and 

provide ìhands-onî coordination 

assistance to States and communities 

(for example, the technical assistance 

ìambassadorsî).

Provides additional 

coordination guidance to 

States and communities.
92 Special Investigation Report

Appendix J

Sixteen Ranked Components From National Highway Traffic 

Safety Administration Survey1

The National Highway Traffic Safety Administration, American Association of

Motor Vehicle Administrators, and TransAnalytics identified 64 medical oversight ìbest

practiceî elements in the Summary of Medical Advisory Boards in the United States.

2

Forty-five representatives from the 50 States and the District of Columbia assessed and

ranked these ìbest practiceî elements. Below are the rankings given to each element (ì1î

being most important), along with the rankings given to more general categories and

components of medical oversight. The top 10 elements are shown in bold font.

1 K. Lococo and L. Staplin, In-Depth Study to Identify Best Practices for Licensing Drivers with

Medical and Functional Impairments and Barriers to Their Implementation, contract DTNH22-02-P-05111,

National Highway Traffic Safety Administration (2004).

2 K.H. Lococo, Summary of Medical Advisory Board Practices in the United States, prepared for the

National Highway Traffic Safety Administration by Transanalytics, contract DTNH22-02-P-0511 (2003).

Rank among 4 

categories

Rank among 16 

components Rank among 64 elements

1 Policies 

governing 

medical review 

activities

1 Comprehensiveness of 

criteria for licensure

3 Standards for blackouts/seizures/losses of 

consciousness (includes mental disorders and 

dementia)

5 Standards for vision

9 Standards for medical conditions affecting multiple 

body systems

19 Standards for alcohol/substance abuse

3 Nature/extent of DMV 

medical advisors mission

2 Develop medical criteria/guidelines for licensing

13 Review individual cases

39 Develop report forms

45 Hear appeals

4 Physician reporting 

responsibilities and 

protections

4 Protection from tort action/immunity for reporting

12 Mandated by law for specified medical conditions

24 Confidential 
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Rank among 4 

categories

Rank among 16 

components Rank among 64 elements

44 Sanctions for failure to report

12 Due process for 

drivers referred for 

medical review

25 Road test

41 No anonymous reports

43 Follow up of reporting source to validate claim

50 Appeal of departmental action

2 Process for 

identifying atrisk drivers

2 Use of external medical triggers for medical reviews1 Personal physician

6 Vision care specialists

18 OT/driving evaluators

31 Hospital discharges planners

6 Extent of DMV testing 

for license renewal

11 Vision

15 Road

21 Functional screening 

30 Knowledge

7 Use of external nonmedical triggers for 

medical reviews

8 Law enforcement/courts

17 Family

22 Social services (includes geriatric evaluation)

53 General public

9 Use of internal triggers 

for medical reviews

26 Observations by counter staff

27 Self-reports

34 Driving history (points, crashes)

54 Age

3 Case review 

procedures

5 Extent of DMV evaluation procedures7 Examination by personal physician

10 Examination by medical specialist (such as a 

neurologist)

23 Driving evaluation (driver rehabilitation or driver training specialist (OT/CDRS, driving school)

49 Clinical/laboratory testing

8 Availability of options 

for preliminary disposition (determines path 

for evaluation)

14 DMV examination (may include vision, knowledge, 

and/or road)

16 Request for and review of medical history

Appendix J
94 Special Investigation Report

Rank among 4 

categories

Rank among 16 

components Rank among 64 elements

28 Functional screening

48 Interview (in-person or video)

13 Availability of options 

for preliminary disposition (determines path 

for evaluation)

32 Assignment by nonmedical staff (administrative determination via procedure manual, checklist)

35 Assignment by nonmedical staff (administrative determination via procedure manual, checklist)

52 Hearing officer interview with driver

58 Voluntary surrender

14 Composition of medical advisory board40 Paid consultants

42 Voluntary consultants

47 Part-time staff physicians

51 Full-time DMV staff physicians

4 Options supporting continuing safe 

mobility

10 Availability of restrictions for license "customization"

20 Daylight/time of day

36 Geographical (for example, radius of home, within city 

limits, not in city limits)

37 Road class exclusion (for example, no freeways, no 

roads with speeds of 45 mph or greater)

63 Specific routes of destinations

11 Scope of DMV staff 

training

29 License examiner (to conduct specialized road tests)

33 License examiners (to conduct functional screening)

38 Counter staff (to recognize signs of functional impairment)

56 Sensitivity training for issues relating to senior drivers 

and drivers with disabilities

15 Breadth of outreach 

activities by DMV

46 Physician education

57 Law enforcement training in signs of impairment

61 Other agencies providing services to seniors

62 Public awareness/injury prevention

16 Type/extent of referrals for at-risk drivers55 Retraining/"skills refresher"

59 Remediation (to correct or ameliorate functional deficits)

60 Alternative transportation

64 Counseling (for adjustment to change in license or functional status)

Appendix J