CONDITION BEING REPORTED
Date of Onset (mm/dd/yyyy) Date of First Specimen Collection (mm/dd/yyyy) Date of Diagnosis (mm/dd/yyyy)
CONFIDENTIAL MORBIDITY REPORT
PLEASE NOTE: Use this form for reporting lapses of consciousness, Alzheimer's disease or other conditions which may impair the
ability to operate a motor vehicle safely (pursuant to H&S 103900).
State of California—Health and Human Services Agency California Department of Public Health
Remarks:
CDPH 110c (07/16) (for reporting conditions reportable to DMV)
DEPARTMENT OF MOTOR VEHICLES (DMV)
1. If this report is based upon episodic lapses of consciousness, when was the most recent episode?: _______________
(mm/dd/yyyy)
2. If there have been multiple episodes of loss of consciousness or control within the past three years, please indicate the dates if they are known to you.
(a): (b): (c): (d): (e): (f):
(mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy) (mm/dd/yyyy)
California Driver License or Identification Card Number (eight characters):
3. Within the past 12 months, has there been an episode of loss of consciousness or control while driving?
Yes No Uncertain
4. Are additional lapses of consciousness likely to occur?
Yes No Uncertain
5. If the patient has had episodes of nocturnal seizures, is there likelihood of lapses of consciousness
occurring while he/she is awake?
Yes No Uncertain
Yes No Uncertain
6. Has this patient been diagnosed with dementia or Alzheimer's disease?
Yes No Uncertain
7. Would you currently advise this patient not to drive because of his/her medical condition?
Yes No Uncertain
8. Does this patient's condition represent a permanent driving disability?
Yes No Uncertain
9. Would you recommend a driving evaluation by DMV?
Primary
Language
Patient Name - Last Name
Home Address: Number, Street
City
Home Telephone Number
First Name MI
Apt./Unit No.
State ZIP Code
Cell Telephone Number Work Telephone Number
Birth Date (mm/dd/yyyy)
Age
Years
Months
Days
Gender
Male
Female
Pregnant?
Est. Delivery Date (mm/dd/yyyy)
Yes No Unknown
Country of Birth
Ethnicity (check one)
Race (check all that apply)
Hispanic/Latino Non-Hispanic/Non-Latino Unknown
African-American/Black
American Indian/Alaska Native
Asian (check all that apply)
Asian Indian Hmong Thai
VietnameseJapaneseCambodian
Other (specify):
KoreanChinese
LaotianFilipino
Pacific Islander (check all that apply)
SamoanNative Hawaiian
Other (specify): ________
Guamanian
White
Other (specify): _______________
Unknown
Occupational or Exposure Setting (check all that apply):Occupation or Job Title
Food Service Day Care Health Care
Correctional Facility School
Other (specify): _______________________________________
M to F Transgender
F to M Transgender
Other: ____________
Email Address
English Spanish
Other: ______________
Reporting Health Care Provider
Address: Number, Street Suite/Unit No.
City
Telephone Number
State ZIP Code
Fax Number
Date Submitted (mm/dd/yyyy)
Submitted by
REPORT TO:
(Obtain additional forms from your local health department.)
Reporting Health Care Facility
Page 1 of 2
County of Santa Cruz
Communicable Disease Unit
1060 Emeline Ave., Bldg F
Santa Cruz, CA 95060
Phone: (831) 454-4114/Fax: (831) 454-5049
After 5:00pm/Weekends/Holidays
Phone: (831) 471-1170
