Use this form for reporting lapses of consciousness or control, Alzheimer's disease or other conditions which may impair the ability to operate a motor vehicle safely (pursuant to H&S 103900 (CDPH 110 C)

Department of Public Health

This government document is issued by Department of Public Health for use in California

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File Details: PDF
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https://www.cdph.ca.gov/CDPH%20Document%20Library/ControlledForms/cdph110c.pdf
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  • Communicable Disease Control

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