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It collects identification and details about any loss of consciousness episodes related to diabetes, including driving-related and non-driving-related events, plus consent and certification of accuracy. The physician section records diagnosis, treatment/medication, cooperation, prognosis for diabetic control, vehicle exercise qualification, and scheduled follow-up examinations. It also provides Minnesota reporting timelines, mailing contact information, and rules for suspension or cancellation if reporting is incomplete or delayed.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/insulin-treated-diabetes-mellitus-report-reporting-form/308811/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/insulin-treated-diabetes-mellitus-report-reporting-form/308811.png","ImageObject",300,407,{"name":92,"@type":93},"Aran","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-10-22","2026-09-20",true,{"@type":102,"interactionType":103,"userInteractionCount":34},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"Who must complete the form, and what information does the driver provide?","Question",{"text":112,"@type":113},"The driver completes identification fields and certifies whether any diabetes-related episodes of loss of consciousness occurred while driving or otherwise. The driver also acknowledges reporting timelines and consequences for late or inaccurate reporting.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"What does the physician have to include in the physician must-complete section?",{"text":117,"@type":113},"The physician provides diagnosis, treatment/medication, whether the patient is cooperating, prognosis for control, and whether the patient is medically qualified to exercise reasonable and ordinary control of a commercial vehicle. The physician also specifies required review intervals and signs the statement.",{"name":119,"@type":110,"acceptedAnswer":120},"What are the key reporting timelines and consequences described in the instructions and Minnesota rules?",{"text":121,"@type":113},"Insulin-treated diabetes diagnoses must be reported when applying for a license and within 30 days after diagnosis. Episodes must be reported within 30 days, and follow-up physician statements follow a six-month, then annual, schedule until episode-free periods are met. Failure to provide complete and accurate information or timely reporting can result in loss of driving privileges, including suspension or cancellation.","https://schema.org",{"og:url":83,"og:type":124,"og:title":65,"og:site_name":95,"og:description":67},"article",{"robots":126,"canonical":83},"index,follow",{"doc_id":128,"site_id":62},308811,1790195874,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":92,"user_avatar":133,"doc_module":4,"category_id":34,"category_name":35,"doc_title":65,"doc_description":67,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":34,"is_deleted":4,"is_public":8,"is_downloadable":8,"audit_status":8,"page_count":14,"language":139,"language_code":63,"site_id":62,"html_lang":63,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":67,"update_tm":143,"read_time":24},137455076865,"https://ap-avatar.wpscdn.com/davatar_29158cc5080c5b710cf443261637dec0","# Insulin-Treated Diabetes Mellitus Report                    \n\nPlease read the instructions on the back of this form carefully before completing.DRIVER COMPLETES THIS SECTION (PRINT OR TYPE)  \nDate of Birth(mm/ddlyy)  \nDriver's License Number  \nFirst Name  \nMiddle Name  \nLast Name  \n1.While driving,operating or in physical control of a motor vehicle,have you had an episode of loss of consciousness due to diabetes?Loss of consciousness means being unable to assume and retain an upright posture without support or being unable to overcome diabetic symptomswithout assistance.  \n□Yes  \n2.Have you had other non-driving related episodes of loss of consciousness?□Yes □No  \nI certify that the information provided above is accurate.I understand that any episode of loss of consciousness that occurs while driving,operating or in physical control of a motor vehicle must be reported to the Minnesota Department of Public Safety,Driver and Vehicle Services.The report must be made within 30 days of the episode If l fail to make this report within 30 days,l understand tha it will result in the loss ofmy driving privileges.  \nX                                 \nSignature  \nDate(mm/ddlyy)  \n## PHYSICIAN MUST COMPLETE\n\nNote to Reporting Physician:Your report is advisory.Driver and Vehicle Services is responsible for determining eligibility to drive.  \nDate(mm/ddyy)                  \n1.Diagnosis                            \n2.Treatment/Medication                                                                                          \n3.Is the patient cooperating with treatment?□Yes  \n4.Prognosis for control of the person's diabetic condition.                                                              \n5.To your knowledge,is the patient qualified,in all medical respects,to exercise reasonable and ordinary control over a:Commercial Vehicle?□YesComments:                                                                                                \n6.A review examination should be required every (check one):□4 years □3years □2 years □1 year □6months  \n7.A six-month or annual review is required until episode-free for four years.No recommendation results in four year review,ifeligible.  \nDate(mm/ddlyy)  \nSignature  \nPrinted name:  \n                        Phone(INCLUDE AREA CODE).           \n## INSTRUCTIONS\n\n·Mail the completed form to Driver and Vehicle Services,Driver Evaluation Unit,445 Minnesota Street,St.Paul,Minnesota55101-5170.  \n·If you have questions or need additional information,please contact DVS at(651)296-2021,(651)282-6555(TTY)oremail:dvs.driverslicense@state.mn.us  \n·  The requested information is needed to determine if your medical condition may interfere with your ability to safely operatea motor vehicle.If your driving privileges are canceled based on the information provided by you or your physician,youhave the right to a review by the Diabetic Medical Review Board.Requests for a review must be submitted in writing toDriver and Vehicle Services at the address listed above.  \n● Reporting requirements for drivers with insulin-treated diabetes are established in Minnesota Rules,chapter 7410.Failure toprovide complete and accurate information will result in the loss of your driving privileges.  \nMINNESOTA RULE 7410.2610-INSULIN-TREATED DIABETES MELLITUS  \nSubp.3.  \n## Reporting diagnosis of insulin-treated diabetes orepisode.\n\nA person shall report a diagnosis of insulin-treated diabetes or an episode,in writing,to the department as follows:  \n### A.after a diagnosis of insulin-treated diabetes:\n\n(1)at the time of applying for a driver's license;and  \n(2)within 30 days after the diagnosis;  \n### B.fora driving-related episode:\n\n(1)within 30 days after the episode;and  \n(2)on a regularly scheduled physician's statement as required in subpart 3a;and  \nC.for a non-driving-related episode,on aregularly scheduled physician's statement as required in subpart 3a.If a person has reason to know the requirements of items A and B,and wilfully fai","cbCaibCBoXCfxNLx","https://ap.wps.com/l/cbCaibCBoXCfxNLx","pdf",255058,"English","# Insulin-Treated Diabetes Mellitus Report\n## DRIVER COMPLETES THIS SECTION\n## PHYSICIAN MUST COMPLETE\n## INSTRUCTIONS\n## MINNESOTA RULE 7410.2610 - INSULIN-TREATED DIABETES MELLITUS","[{\"question\":\"Who must complete the form, and what information does the driver provide?\",\"answer\":\"The driver completes identification fields and certifies whether any diabetes-related episodes of loss of consciousness occurred while driving or otherwise. The driver also acknowledges reporting timelines and consequences for late or inaccurate reporting.\"},{\"question\":\"What does the physician have to include in the physician must-complete section?\",\"answer\":\"The physician provides diagnosis, treatment/medication, whether the patient is cooperating, prognosis for control, and whether the patient is medically qualified to exercise reasonable and ordinary control of a commercial vehicle. The physician also specifies required review intervals and signs the statement.\"},{\"question\":\"What are the key reporting timelines and consequences described in the instructions and Minnesota rules?\",\"answer\":\"Insulin-treated diabetes diagnoses must be reported when applying for a license and within 30 days after diagnosis. Episodes must be reported within 30 days, and follow-up physician statements follow a six-month, then annual, schedule until episode-free periods are met. Failure to provide complete and accurate information or timely reporting can result in loss of driving privileges, including suspension or cancellation.\"}]","Insulin-Treated Diabetes Mellitus Report - Reporting Form | PDF",1789872455]