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APPENDIX B: DATA COLLECTION INSTRUMENT FOR SURVEY OF STATE PRACTICES

DATE: January 8, 2003

TO: Driver Licensing Contacts and Medical Advisory Board Contacts

FROM: Michael R. Calvin, Senior Vice President, Programs Division

RE: Medical Advisory Board Project Survey

On behalf of the National Highway Traffic Safety Administration and its contractor, TransAnalytics, enclosed is the comprehensive survey mentioned in my memorandum dated October 30. The survey will be used to document the processes the jurisdictions follow in licensing drivers with medical conditions and functional impairments. As you respond to the questions on the following pages, you are encouraged to write in additional information to help describe the organization and operations of your State’s Medical Advisory Board (or other unit that addresses drivers with medical conditions and/or with impairments of the functional abilities—visual, physical, and mental—needed to drive safely).

There are three sections to this survey. You should complete Section 1, and then complete either Section 2 or Section 3, depending on whether your State/District has a Medical Advisory Board. When checking the response “Other,” please provide a description of what this may entail.

Section 1—to be completed by all Licensing Agencies, whether or not they have a Medical Advisory Board.

Section 2—to be completed by States/Districts that HAVE a Medical Advisory Board (MAB), Health Advisory Board (HAB), or Medical Advisory Panel.

Section 3—to be completed by States/Districts that DO NOT HAVE a Medical Advisory Board/Health Advisory Board/Medical Advisory Panel.

Additional documentation is also requested such as forms, training materials and sections of your jurisdiction’s Vehicle Code. A checklist of requested materials is attached.

TransAnalytics will summarize all survey results. They will also prepare a final report for NHTSA that summarizes the practices of all 50 states and the District of Columbia, highlighting recommended strategies identified in this research. This information will be made available to the jurisdictions.

We realize that this survey is quite extensive. If you have questions about specific items, please contact Kathy Lococo of TransAnalytics at 215-855-5380. We appreciate your patience in taking the time to provide thoughtful, complete answers.

Please complete and return the survey by Wednesday, January 29. Thank you!

Completed surveys and attached documentation should be mailed to
the following address:

Kathy H. Lococo
TransAnalytics, LLC
P.O. Box 328, 1722 Sumneytown Pike
Kulpsville, PA 19443

PDF files are attached below to print and to be filled out:

Section 1

Section 2

Section 3

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