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Priority Reexamination
If you come in contact with law enforcement and receive a Notice
of Priority Reexamination of Driver with a check mark in the top box
carefully read the form. You have ve working days to contact DMV
to initiate the process or your driving privilege will be automatically
suspended.
REQUEST FOR REGULAR RE-EXAMINATION OF DRIVER (Ocer’s Instructions on reverse.)
The driver listed below should be re-examined by DMV, but does not require a Priority Re-examination.
OBSERVED DRIVING BEHAVIOR—Check appropriate boxes for driving problems you observed: (Use space below if needed for additional comments.)
DATE TIME DRIVER LICENSE NO. STATE BIRTHDATE
NAME (FIRST, MIDDLE, LAST)
MAILING ADDRESS
CITY STATE ZIP CODE DRIVER’S DAYTIME PHONE NO.
LOCATION OF INCIDENT
ANY NOTICE TO APPEAR NO. (IF CITATION ISSUED, ATTACH COPY)
ACCIDENT/ARREST NO. (ATTACH COPY IF APPLICABLE) CITY COUNTY
FOR DMV USE ONLY
X - ( )
NOTICE OF PRIORITY RE-EXAMINATION OF DRIVER (Driver Incapacity)
The driver listed below committed a violation of the California Vehicle Code (CVC) §§21000 through 23336 and should be
re-examined pursuant to CVC §21061. At the time of the violation, the driver exhibited evidence of incapacity which reasonably
led me to believe that this person is not capable of operating a motor vehicle without presenting a clear or potential danger, or
risk of injury to himself/herself or others. As required by law, on the date below, I issued a copy of this Notice of Priority
Re-examination/Notice of Suspension for Non-Compliance to the driver listed below.
The driver does not have to be cited for one of the above CVC sections. Please indicate evidence of the incapacity in the
Summary area below. If the driver was involved in a trac accident, attach a copy of the report. You must give a copy of
this form to the driver.
If this form is being issued as a Notice of Priority Re-examination/Notice of Suspension for Non-Compliance, immediately
fax the document (if fax available) to the Driver Safety Oce nearest the driver’s home (see reverse), then mail the original
Notice to the same oce.
NOTICE OF SUSPENSION FOR NON-COMPLIANCE
INSTRUCTIONS TO DRIVER
If the above box is checked, you must contact the Department of Motor Vehicles (DMV) for a re-examination under CVC §§12818
and 12819. If you do not call or appear within ve (5) working days, your privilege to drive in this state will be suspended until you
satisfactorily complete a re-examination. SEE IMPORTANT PRIORITY RE-EXAMINATION INFORMATION ON THE REVERSE
SIDE OF THIS FORM.
DS 427 (REV. 10/2018)
Yes No
( )
AGENCY TELEPHONE NO.
STREET ADDRESS CITY ZIP CODE
OFFICER NAME (PLEASE PRINT) BADGE OR I.D. NUMBER
OFFICER’S SIGNATURE DATE DATE FAXED DO YOU WISH TO BE NOTIFIED OF RESULTS?
I certify (or declare) under penalty of perjury under the laws of the State of California that the information I have
provided is true and correct.
X
SUMMARY: You may use the space below to further describe actions of the driver which led you to believe a re-examination
is needed - describe any impairment, serious physical injury or illness, mental impairment or disorientation. Describe any
trac law violations whether or not a citation was issued.
Confused, disoriented, incoherent, or unaware of actions
Reported/Observed Medical Condition
Little or no recollection of incident
Medicated
Vision Condition/Visual Impairment
Mental/Emotional Condition
Driver reported he/she did not see cars, pedestrians, etc.
Diculty Walking
Weakness or Coordination Problems
Responding incorrectly to Emergency Signal/Lights
Drifting or weaving in and out of lanes
Caused, or nearly caused, collision
Not reacting to other cars, pedestrians, etc.
Driving on wrong side of road
Driving on sidewalk
Driving in wrong lane
Driving too slow, impeding trac
Failed to stop at red light/stop sign
Unsafe/inappropriate lane change
Inappropriately stopped
Failed to yield right-of-way
Lost control of vehicle
Struck stationary object
Failed to go on green light
Driving without lights during darkness
Made turn from wrong lane
Fell asleep while driving
Violent or aggressive driving
Not adequately controlling vehicle
Other Observations _________________________________________
____________________________________________________________
DRIVER CONDITION (Observations after Stop/Collision)—Check all appropriate boxes below. Please use the space below to provide specic
details, if known, and the driver’s medical (physical or mental) condition such as name of disease or illness, any medications taken, etc.
Alcohol/Drug Use (Describe below)
Confused by trac
Lost or confused while driving near home
Blackout/Seizure/Fainting
Driver appears to need help with hygiene
and/or dressing appropriately
Other Observations _________________________________________
____________________________________________________________
Destroy all previous versions of this form.
White: DMV Canary: Law Enforcement Pink: Driver (Priority Re-Exam Only)
,
Driver’s License Restrictions
DMV places restrictions on a driver’s license to ensure a driver is
operating a vehicle within their ability. Restrictions may be imposed by
DMV or required by law. Restrictions placed on your driving privilege will
be reasonable and necessary for your safety and the safety of others.
Restrictions and conditions may include:
• Requiring a driver to place special mechanical devices on their
vehicle, such as hand controls.
• Limiting when and where a person may drive, such as no night or
freeway driving.
• Requiring eyeglasses or corrective contact lenses.
• Requiring additional devices, such as outside mirrors.
NOTE: There are no specic restrictions for seniors. All restrictions are
based on conditions, not age.
Any restriction placed on your driver’s license is based on the examiner’s
ndings and recommendations.