2010 BC Guide in Determining Fitness to Drive

11.17 Driver’s report – commercial driver with diabetes on insulinOffice of the Superintendentof Motor Vehicleswww.pssg.gov.bc.ca/osmvPO BOX 9254 STNPROV GOVTVICTORIA BC V8W 9J2Phone: (250) 387-7747Fax: (250) 952-6888The personal information on this form is collected under the authority of the Motor Vehicle Act (RSBC 1996, c.318, s. 29) and the Freedom of Information andProtection of Privacy Act (RSBC 1996, c.165, s26(b) & s. 27(1)(c). The information provided will be used to determine your fitness to drive a motor ve hicle. If youhave any questions about the collection, use and disclosure of the information collected, contact the Office of the Superintendent of Motor Ve hicles at (250) 387-7747DRIVER’S REPORT – COMMERCIAL DRIVER WITH DIABETES ON INSULINDriver’s Name DL # Date Issued1. Can you recognize a hypoglycemic reaction when it occurs? YES NO2. Please list the symptoms you would experience during a hypoglycemic reaction:__________________________________________________________________________________________________________________________________________________________3. How would you treat a hypoglycemic reaction?_____________________________________________________________________________4. Do you carry food and glucose (sugar) on your person? YES NO5. In the last year have you had a hypoglycemic reaction where you lost consciousness or where yourequired assistance of another person to treat the hypoglycemia? YES NOIf yes describe: _________________________________________________________________6. In the last year have you had an episode of hypoglycemic unawareness? YES NOIf yes describe: _________________________________________________________________DRIVER’S CERTIFICATION:I agree that while I hold a British Columbia class 1, 2, 3, or 4 driver’s licence, I will:Carry blood glucose monitoring equipment and a source of readily available, rapidly absorbable glucoseCheck my blood glucose within 1 hour or less before driving and approximately every 4 hours whiledrivingNot drive when my blood glucose is less than 6 mmol/L. and I will not resume driving until my bloodglucose levels have risen to 6.0mmol/L or higher following food ingestionMake available to my doctor records of medical care for the previous 24 months for initial assessment and12 months for re-assessment, andMaintain a log of blood glucose measurements performed at least twice daily for the previous six monthsor since diagnosis if diagnosed less than six months previous, andRecord the hours driven and blood glucose checks during that time in the glycemic log, and110