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Indicate Reason for Evaluation 2022-2026

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828. 2000 888. 99-VERMONT dmv.vermont. gov THIS EVALUATION MUST BE COMPLETED I N FULL OR I T WILL BE RETURNED ANY MEDICAL CHARGES INCURRED ARE THE RESPONSIBILITY OF THE PATIENT Indicate Reason for Evaluation Complete Sections A B D E if you are selecting one of the four reasons below. For other licensed drivers only indicate if a medical condition exists. RATER VS-113 5M 12/2016 MTC DEPARTMENT USE ONLY SECTION TRANSACTION TYPE TYPE ADD A SCHOOL BUS UPDATE B NOT STABLE Systolic Diastolic MEDICAL DATE MM/DD/YYYY D STABLE CONTINUED SECTIONS C D E To Be Completed By Medical Examiner SECTION C Parking Placard/Plates I hereby attest to the fact that at the time of the examination the applicant Check-mark the applicable disability. Universal Medical Evaluation/Progress Report 120 State street Montpelier Vermont 05603-0001 Department of Motor Vehicles Agency of Transportation 802. Statements and warrants herein are certified under penalty of 23 V. S.A. 202 203. APPLICANT S SIGNATURE SECTIONS B C D E To Be Completed By Medical Examiner SECTION B 1. See front and back of form. Applying for a Vermont License/Permit Department Request School Bus Endorsement Type II New/Update Medical Condition Complete ALL Sections if requesting a DISABLED PLACARD OR PLATES. See front and back of form. Disabled Parking Placard must also submit a completed Disabled Parking Placard Application VD-120 Parking Placard Applicants The Information In This Medical May Be Considered In Determining Your License Status SECTION A - To Be Completed By Applicant Patient s Name Street / Road / Box Number Patient s Mailing Address City / State / Zip Code Physical Address If Different From Mailing Address Gender Mailing Address Physical Address Check If The Above Is A Change To Your Date Of Birth Social Security Number VT Driver License/Id Number If This Is A Name Change List Former Name I certify that the information contained above is true complete and correct to the best of my knowledge. 2. If the applicant has or is applying for a Vermont license without a School Bus endorsement the medical must be signed by a Licensed Physician. Exception A Physician Assistant may sign the medical if co-signed by a Licensed Physician. herein are certified under penalty of 23 V. Patient has been under my care for years. 2. Check any of the following conditions that apply Seizures Cancer Spinal Injury Hypertension Diabetes COPD Arthritis/Degenerative Joint Disease Amputation Permanent Disability/Condition Psychiatric Disorder Specify Arm Left Right Leg Describe cause and extent example at elbow below knee of amputation Blood pressure reading is required for all school bus driver medicals. One must be check-marked. Has an irreversible visual impairment or SECTION D Medical Examiner s Opinion 1. I have examined the patient and in my opinion Check-mark one of the statements below. The patient IS NOT medically fit to drive any motor vehicle on the highway. Comments 2. Patient s condition is totally stable Yes Years No THIS FORM MUST BE COMPLETED BY A LICENSED PHYSICIAN EXCEPT AS STATED BELOW* 1.

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What is the Indicate Reason For Evaluation

The Indicate Reason For Evaluation is a crucial component of the Vermont vs 113 form, designed to clarify the specific circumstances that necessitate the evaluation. This section allows individuals to articulate the reasons behind their request, ensuring that the evaluation process is tailored to their unique situations. Common reasons for evaluation may include health concerns, changes in personal circumstances, or eligibility for specific programs. Accurately filling out this section is essential for a comprehensive assessment.

Steps to complete the Indicate Reason For Evaluation

Completing the Indicate Reason For Evaluation section requires careful attention to detail. Follow these steps to ensure accuracy:

  • Begin by clearly stating the reason for the evaluation. Use straightforward language to describe your situation.
  • Provide any relevant details that support your reason. This may include dates, specific incidents, or changes in your health or circumstances.
  • Review your entry for clarity and completeness. Ensure that all necessary information is included.
  • Consult with a professional if you have questions about what to include or how to phrase your reason.

Legal use of the Indicate Reason For Evaluation

The Indicate Reason For Evaluation section is not only a procedural formality but also holds legal significance. It serves as a formal declaration that can impact eligibility for various programs and services. Providing accurate and truthful information is essential, as any discrepancies may lead to legal consequences or delays in processing. Understanding the legal implications of your statements can help ensure compliance with state regulations.

Examples of using the Indicate Reason For Evaluation

Utilizing the Indicate Reason For Evaluation effectively can enhance the clarity of your submission. Here are some examples:

  • If you are seeking an evaluation due to a recent diagnosis, specify the condition and how it affects your daily life.
  • For changes in financial circumstances, outline the events that led to the change, such as job loss or increased medical expenses.
  • In cases of relocation, detail how the move impacts your eligibility for services in Vermont.

Required Documents

When submitting the Vermont vs 113 form, certain documents may be required to support your Indicate Reason For Evaluation. These documents can include:

  • Medical records or letters from healthcare providers.
  • Financial statements or proof of income.
  • Any relevant legal documents that pertain to your situation.

Gathering these documents in advance can streamline the evaluation process and help ensure that your request is processed efficiently.

Form Submission Methods

The Vermont vs 113 form can be submitted through various methods to accommodate different preferences. You can choose from:

  • Online submission via the official state portal, which allows for quick processing.
  • Mailing a physical copy to the designated state office, ensuring you use the correct address.
  • In-person submission at local offices, which may provide immediate assistance and clarification.

Choosing the right submission method can impact the speed and efficiency of your evaluation.

Quick guide on how to complete indicate reason for evaluation

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VersionsForm popularityFillable & printable
2011 VT TA-VS-113 [2011-02] 20224.8 Satisfied (133 Votes)
2011 VT TA-VS-113 [2011-02] 20164.8 Satisfied (2698 Votes)
2011 VT TA-VS-113 [2011-02] 20114.8 Satisfied (5802 Votes)
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