Blank Dl 51 Template

MeDiCal eXaMination RePoRt

instRuCtions to the DRiveR

A Public Service Agency

You must use this medical examination report when applying for a Commercial California Driver License (CDL) or certiicates (School Bus,Youth Bus, SPAB, GPPV, or Farm Labor) that require a medical examination. This report also meets United States DepartmentofTransportation(DOT)requirements.A driver who does not meet DOT’s medical standards may, after evaluation by the Department of Motor Vehicles (DMV), be issued a restricted license if DMV determines the driver’s condition will not affect his or her ability to drive safely.

•Drivers applying for, or who hold, a certiicate to drive a School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle must have their examination performed by a Physician Assistant, Advanced Practice Registered Nurse, Doctor of Medicine (MD), Doctor of Osteopathy (DO) or a Doctor of Chiropractic (DC) listed on the most current NationalRegistry.TheMedicalExaminationReport and Medical Certiicate must be signed by the medicalexaminerwhoperformedtheexamination.

•School bus drivers 65 years of age and older must submit a new medical report to DMV every year. (Vehicle Code Section 12517.2b)

•TheHealthQuestionnaire(DL546)maybeusedby drivers with a Restricted Fireighter’s License or a Non-CommercialClassCLicensewithaFireighter endorsement rather than this medical report.

•The Health Questionnaire (DL 546) may also be used by drivers applying for a Non-Commercial

Class A license and those drivers who need the Agricultural Hazardous Materials or Waste Transportation Veriication of Training.

nationalReGistRyoFMeDiCaleXaMineRs BeginningMay21,2014,interstatecommercialmotor vehicledriversmusthavetheirmedicalexamination performed by a certiied medical examiner listed on theNationalRegistryofCertiiedMedicalExaminers (National Registry). A list of certiied medical examiners may be found on the National Registry Website https://nationalregistry.fmcsa.dot.gov

Class a, B, or Commercial C license

CDL drivers who have submitted a current medical examination report to DMV documenting they meet the physical qualiication requirements, no longer need to carry the medical examiner’s certiicate for more than 15 days after the date it was issued.You are required to give a medical report to DMV when you irst apply for the license and every two years thereafter. If the medical report is incomplete, your license application will be delayed or denied.

If you qualify by using a hearing aid, you must wear the hearing aid and use it whenever you are driving. Also, you must keep with you a spare power source to use in the hearing aid.

Federal Law requires that you disclose the type of commercial operation you are engaged in.

•Non-Excepted Interstate:License does not restrict the transport, origination, or destination of the load to be transported.

•Non-Excepted Intrastate: License is restricted to operation in California only.You may only transport cargo that originates in and the inal destination is in California. While driving commercially you may not cross state or international borders.

•Excepted Interstate: California does not issue a commercial driver license that is excepted from driver qualiication requirements.

•Excepted Intrastate: California does not issue a commercial driver license that is excepted from driver qualiication requirements.

Drivers renewing their medical certiicate may mail this report to:

Department of Motor Vehicles CDL Unit, G204

P. O. Box 944278

Sacramento, CA 94244-2780

If you are required to have a CDL as part of your job, your employer shall pay the cost of the examination unless it was taken before you applied for the job (Labor Code §231).

information on Drug testing

Federal regulations and state law have established minimum standards for commercial motor carriers’ antidrug programs including testing for the use of controlled substances. This testing requirement applies to drivers required to have a Commercial drivers license.

Youremployerwilltellyouwhetherornotyourmedical exam should include a drug test.

(a)(1)(i) A person subject to this part must not operate a commercial motor vehicle unless he or she is medically certiied as physically quali- ied to do so, and, except as provided in para- graph (a)(2) of this section, when on-duty has on his or her person the original, or a copy, of a current medical examiner’s certiicate that he or she is physically qualiied to drive a commercial motor vehicle.

(ii)A person who qualiies for the medical ex- aminer’s certiicate by virtue of having obtained a medical variance from FMCSA, in the form of an exemption letter or a skill performance evalu- ation certiicate must have on his or her person a copy of the variance documentation when on- duty.

(2)CDL exception. (i) Beginning January 30,

2014, a driver required to have a commercial driver’s license under part 383 of this chapter, and who submitted a current medical examiner’s certiicate to the State in accordance with § 383.71(h) of this chapter documenting that he or she meets the physical qualiication require- ments of this part, no longer needs to carry on his or her person the medical examiner’s certii- cate speciied at §391.43(h), or a copy for more than 15 days after the date it was issued as valid proof of medical certiication.

(ii)A CDL holder required by §383.71(h) to obtain a medical examiner’s certiicate, who obtained such by virtue of having obtained a

medical variance from FMCSA, must continue to have in his or her possession the original or copy of that medical variance documentation at all times when on-duty.

(3)A person is physically qualiied to drive a commercial motor vehicle if:

(i) That person meets the physical qualiica- tion standards in paragraph (b) of this section and has complied with the medical examination requirements in §391.43; or

(ii)That person obtained from FMCSA a medi- cal variance from the physical qualiication stan- dards in paragraph (b) of this section and has complied with the medical examination require- ment in §391.43.

(b)A person is physically qualiied to drive a motor vehicle if that person:

(1)Has no loss of a foot, a leg, a hand, or an arm, or has been granted a Skill Performance

Evaluation (SPE) Certiicate (formerly LimbWaiver Program) pursuant to §391.49.

(2)Has no impairment of:(i)A hand or inger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or any other signiicant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or has been granted a SPE certiicate pursuant to §391.49.

(3)Has no established medical history or

clinical diagnosis of diabetes mellitus currently requiring insulin for control.

(4)Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure.

(5)Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his ability to control and drive a commercial motor vehicle safely.

(6)Has no current clinical diagnosis of high blood pressure likely to interfere with his ability to operate a commercial motor vehicle safely.

(7)Has no established medical history or clinicaldiagnosisofrheumatic,arthritic,orthopedic, muscular, neuromuscular, or vascular disease which interferes with his ability to control and operate a commercial motor vehicle safely.

(8)Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a commercial motor vehicle.

(9)Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his ability to drive a commercial motor vehicle safely.

(10)Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected to 20/40

(Snellen) or better with corrective lenses, distinct binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, ield of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green and amber.

(11)First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by

use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated toAmerican National Standard (formerly ASA Standard) Z24.5-1951.

(12)(i) Does not use any drug or substance identiied in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit- forming drug. (ii) Does not use any non-Schedule

I drug or substance that is identiied in the other Schedules in 21 part 1308 except when the use is prescribed by a licensed medical practitioner, as deined in § 382.107, who is familiar with driver’s medical history and has advised the driver that the substance will not adversely affect the driver’s ability to safely operate a commercial motor vehicle.

(13)Has no current clinical diagnosis of

alcoholism.

loss of limb: §391.41(b)(1)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no loss of a foot, leg, hand or an arm, or has been granted a Skill Performance Evaluation (SPE) Certiicate pursuant to §391.49.

limb impairment: §391.41(b)(2)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no impairment of: (i) A hand or inger which interferes with prehension or power grasping; or

(ii)An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or Any other signiicant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or Has been granted a Skill Performance Evaluation (SPE) Certiicate pursuant to §391.49.

A person who suffers loss of a foot, leg hand or arm or whose limb impairment in any way interferes with the safe performance of normal tasks associated with operating a commercial motor vehicle is subject to the Skill Performance Evaluation (SPE) Certiication Program pursuant to §391.49, assuming the person is otherwise qualiied.

With the advancement of technology, medical aids and equipment modiications have been developed to compensate for certain disabilities. The SPE Certiication Program (formerly the Limb

Federal Motor Carrier safety Regulations

advisory Criteria

Waiver Program) was designed to allow persons with the loss of a foot or limb or with functional impairment to qualify under the Federal Motor Carrier Safety Regulations (FMCSRs) by use of prosthetic devices or equipment modiications which enable them to safely operate a commercial motor vehicle. Since there are no medical aids equivalent to the original body or limb, certain risks are still present, and thus restrictions may be included on individual SPE certiicates when a State Director for the FMCSA determines they are necessary to be consistent with safety and public interest.

If the driver is found otherwise medically qualiied (§391.41(b)(3) through (13)), the medical examiner must check on the medical certiicate that the driver is qualiied only if accompanied by a SPE certiicate. The driver and the employing motor carrier are subject to appropriate penalty if the driver operates a commercial motor vehicle in interstate or foreign commerce without a current SPE certiicate for his/her physical disability.

Diabetes: §391.41(b)(3)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.

Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or disorientation in time and space. Individuals who

require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semi-consciousness, diabetic coma or insulin shock).

The administration of insulin is, within itself, a complicated process requiring insulin, syringe, needle, alcohol sponge and a sterile technique. Factors related to long-haul commercial motor vehicle operations, such as fatigue, lack of sleep, poor diet, emotional conditions, stress, and concomitant illness, compound the dangers. The FMCSA has consistently held that a diabetic who uses insulin for control does not meet the minimum physical requirements of the FMCSRs.

Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualiied under the present rule. CMV drivers who do not meet the Federal diabetes standard may call (202) 366-4001 for an application for a diabetes exemption. (See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm).

Cardiovascular Condition: §391.41(b)(4)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no current clinical diagnosis of myocardial infarction,angina pectoris,coronary insufficiency, thrombosis or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse or congestive cardiac failure.

The term “has no current clinical diagnosis of” is speciically designed to encompass: “a clinical diagnosis of” (1) a current cardiovascular condition, or (2) a cardiovascular condition which has not fully stabilized regardless of the time limit. The term “known to be accompanied by” is designed to include: a clinical diagnosis of a cardiovascular disease (1) which is accompanied by symptoms of syncope, dyspnea, collapse or congestive cardiac failure; and/or (2) which is likely to cause syncope, dyspnea, collapse or congestive cardiac failure.

It is the intent of the FMCSRs to render unqualified, a driver who has a current cardiovascular disease which is accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiac failure. However, the subjective decision of whether the nature and severity of an individual’s condition will likely cause symptoms of cardiovascular insufficiency is on an individual basis and qualiication rests with the medical examiner and the motor carrier. In those cases where there is an occurrence of cardiovascular insufficiency (myocardial infarction, thrombosis, etc), it is suggested before a driver is certiied that he or she have a normal resting and stress electrocardiogram (ECG), no residual complications and no physical limitations, and is taking no medication likely to interfere with safe driving.

Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus, not unqualifying.Implantable cardioverter defibrillators are disqualifying due to risk of syncope. Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver.The emphasis should be on the underlying medical conditions(s) which require treatment and the general health of the driver. The FMCSA should be contacted at (202) 366- 4001 for additional recommendations regarding the physical qualiication of drivers on coumadin. (See Cardiovascular Advisory Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

Respiratory Dysfunction §391.41(b)(5)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with ability to control and drive a commercial motor vehicle safely.

Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving.

There are many conditions that interfere with oxygen exchange and may result in incapacitation, including emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis and sleep apnea. If the medical examiner detects a respiratory dysfunction, that in any way is likely to interfere with the driver’s ability to safely control and drive a commercial motor vehicle, the driver must be referred to a specialist for further evaluation and therapy. Anticoagulation therapy for deep vein thrombosis and/or pulmonary thromboembolism is not unqualifying once optimum dose is achieved, provided lower extremity venous examinations remain normal and the treating physician gives a favorable recommendation. (See Conference on Pulmonary/Respiratory Disorders

DL 51 (REV. 1/2014) WWW FEDERAL REGULATIONS - PAGE 3

and Commercial Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

hypertension §391.41(b)(6)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no current clinical diagnosis of high blood pressure likely to interfere with the ability to operate a commercial motor vehicle safely.

Hypertension alone is unlikely to cause sudden collapse; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present. This regulatory criteria is based on FMCSA’s Cardiovascular Advisory Guidelines for the Examination of CMV Drivers, which used the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1997).

Stage 1 hypertension corresponds to a systolic BP of 140-159 mmHg and/or a diastolic BP of 90-99 mmHg. The driver with a BP in this range is at low risk for hypertension-related acute incapacitation and may be medically certiied to drive for a one-year period. Certification examination should be done annually thereafter and should be at or less than 140/90. If less than 160/100, certiication may be extended one time for 3 months.

Ablood pressure of 160-179 systolic and/ or 100-109 diastolic is considered Stage 2 hypertension, and the driver is not necessarily unqualified during evaluation and institution of treatment. The driver is given a one time certiication of three months to reduce his or her blood pressure to less than or equal to 140/90.

A blood pressure in this range is an absolute indication for anti-hypertensive drug therapy. Provided treatment is well tolerated and the driver demonstrates a BP value of 140/90 or less, he or she may be certiied for one year from date of the initial exam. The driver is certiied annually thereafter.

A blood pressure at or greater than 180 (systolic) and 110 (diastolic) is considered Stage 3, high risk for an acute BP-related event. The driver may be not qualiied, even temporarily, until reduced to 140/90 or less and treatment is well tolerated.The driver may be certiied for 6 months and biannually (every 6 months) thereafter if at recheck BP is 140/90 or less.

Annual recertiication is recommended if the medical examiner does not know the severity of hypertension prior to treatment.

An elevated blood pressure inding should be confirmed by at least two subsequent measurements on different days.

Treatment includes nonpharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors. Most antihypertensive medications also have side effects, the importance of which must be judged on an individual basis. Individuals must be alerted to the hazards of these medications while driving. Side effects of somnolence or syncope are particularly undesirable in commercial drivers.

Secondary hypertension is based on the above stages. Evaluation is warranted if patient is persistently hypertensive on maximal or near- maximual doses of 2-3 pharmacologic agents. Some causes of secondary hypertension may be amenable to surgical intervention or speciic pharmacologic treatment.

(See Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

Rheumatic, arthritic, orthopedic, Muscular, neuromuscular or vascular Disease §391.41(b)(7)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease

which interferes with the ability to control and operate a commercial motor vehicle safely.

Certain diseases are known to have acute episodes of transient muscle weakness, poor muscular coordination (ataxia), abnormal sensations (paresthesia), decreased muscular tone (hypotonia), visual disturbances and pain which may be suddenly incapacitating. With each recurring episode, these symptoms may become more pronounced and remain for longer periods of time. Other diseases have more insidious onsets and display symptoms of muscle wasting (atrophy), swelling and paresthesia which may not suddenly incapacitate a person but may restrict his/her movements and eventually interfere with the ability to safely operate a motor vehicle. In many instances these diseases are degenerative in nature or may result in deterioration of the involved area.

Once the individual has been diagnosed as having a rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease, then he/she has an established history of that disease. The physician, when examining an individual should consider the following: (1) the nature and severity of the individual’s condition (such as sensory loss or loss of strength); (2) the degree of limitation present (such as range of motion); (3) the likelihood of progressive limitation (not always present initially but may manifest itself over time); and (4) the likelihood of sudden incapacitation. If severe functional impairment exists, the driver does not qualify. In cases where more frequent monitoring is required, a certiicate for a shorter period of time may be issued.

(See Conference on Neurological Disorders and Commercial Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

epilepsy §391.41(b)(8)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a motor vehicle.

Epilepsy is a chronic functional disease characterized by seizures or episodes that occur without warning, resulting in loss of voluntary control which may lead to loss of consciousness and/or seizures. Therefore, the following drivers cannot be qualiied: (1) a driver who has a medical history of epilepsy; (2) a driver who has a current clinical diagnosis of epilepsy; or (3) a driver who is taking antiseizure medication.

If an individual has had a sudden episode of a nonepileptic seizure or loss of consciousness of unknown cause which did not require antiseizure medication, the decision as to whether that person’s condition will likely cause loss of consciousness or loss of ability to control a motor vehicle is made on an individual basis by the medical examiner in consultation with the treating physician. Before certiication is considered, it is suggested that a 6-month waiting period elapse from the time of the episode. Following the waiting period, it is suggested that the individual have a complete neurological examination. If the results of the examination are negative and antiseizure medication is not required, then the driver may be qualiied.

In those individual cases where a driver has a seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction, high temperature, acute infectious disease, dehydration or acute metabolic disturbance), certification should be deferred until the driver has fully recovered from that condition and has no existing residual complications, and is not taking antiseizure medication. Drivers with a history of epilepsy/ seizures off antiseizure medication and seizure- free for 10 years may be qualiied to drive a CMV in interstate commerce. Interstate drivers with a history of a single unprovoked seizure may be qualiied to drive a CMV in interstate commerce

if seizure-free and off antiseizure medication for a 5-year period or more.

(See Conference on Neurological Disorders and Commercial Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

Mental Disorders §391.41(b)(9)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no mental, nervous, organic or functional disease or psychiatric disorder likely to interfere with the ability to drive a motor vehicle safely.

Emotional or adjustment problems contribute directly to an individual’s level of memory, reasoning, attention and judgment.These problems often underlie physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness or paralysis that may lead to incoordination, inattention, loss of functional control and susceptibility to accidents while driving. Physical fatigue, headache, impaired coordination, recurring physical ailments and chronic “nagging” pain may be present to such a degree that certiication for commercial driving is inadvisable. Somatic and psychosomatic complaints should be thoroughly examined when determining an individual’s overall itness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualiication.

Many bus and truck drivers have documented that “nervous trouble” related to neurotic, personality, emotional or adjustment problems is responsible for a signiicant fraction of their preventable accidents. The degree to which an individual is able to appreciate, evaluate and adequately respond to environmental strain and emotional stress is critical when assessing an individual’s mental alertness and lexibility to cope with the stresses of commercial motor vehicle driving.

When examining the driver, it should be kept in mind that individuals who live under chronic emotional upsets may have deeply ingrained maladaptive or erratic behavior patterns. Excessively antagonistic, instinctive, impulsive, openly aggressive, paranoid or severely depressed behavior greatly interfere with the driver’s ability to drive safely. Those individuals who are highly susceptible to frequent states of emotional instability (schizophrenia, affective psychoses, paranoia, anxiety or depressive neuroses) may warrant disqualiication. Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination. See Psychiatric Conference Report for speciic recommendations on the use of these medications and potential hazards for driving.

(See Conference on Psychiatric Disorders and Commercial Drivers at:

w w w . f m c s a . d o t . g o v / r u l e s r e g s / medreports.htm)

vision §391.41(b)(10)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, ield of vision of at least 70 degrees in the horizontal meridian in each eye,and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.

The term “ability to recognize the colors of” is interpreted to mean if a person can recognize and distinguish among traffic control signals and devices showing standard red, green and amber, he or she meets the minimum standard, even though he or she may have some type of color perception deiciency. If certain color perception tests are administered, (such as Ishihara, Pseudoisochromatic, Yarn) and doubtful indings are discovered, a controlled test using signal red, green and amber may be employed to determine the driver’s ability to recognize these colors.

Contact lenses are permissible if there is sufficient evidence to indicate that the driver has good tolerance and is well adapted to their use. Use of a contact lens in one eye for distance visual acuity and another lens in the other eye for near vision is not acceptable, nor are telescopic lenses acceptable for the driving of commercial motor vehicles.

If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner’s Certiicate: “Qualiied only if wearing corrective lenses”.

CMV drivers who do not meet the Federal Vision Standard may call (202) 366-4001 for an application for a vision exemption.

(See Visual Disorders and Commercial Drivers at: w w w . f m c s a . d o t . g o v / r u l e s r e g s / medreports.htm)

hearing §391.41(b)(11)

A person is physically qualified to drive a commercial motor vehicle if that person:

First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometic deviceiscalibratedtoAmericanNationalStandard (formerly ASA Standard) Z24.5-1951.

Since the prescribed standard under the FMCSRs is the American Standards Association (ANSI), it may be necessary to convert the audiometic results from the ISO standard to the ANSI standard. Instructions are included on the Medical Examination report form.

If an individual meets the criteria by using a hearing aid, the driver must wear that hearing aid and have it in operation at all times while driving. Also, the driver must be in possession of a spare power source for the hearing aid.

For the whispered voice test, the individual should be stationed at least 5 feet from the examiner with the ear being tested turned toward the examiner. The other ear is covered. Using the breath which remains after a normal expiration, the examiner whispers words or random numbers such as 66, 18, 23, etc. The examiner should not use only sibilants (s-sounding test materials).The opposite ear should be tested in the same manner. If the individual fails the whispered voice test, the audiometric test should be administered.

If an individual meets the criteria by the use of a hearing aid, the following statement must appear on the Medical Examiner’s Certiicate: “Qualiied only when wearing a hearing aid”.

(See Hearing Disorders and Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

Drug use §391.41(b)(12)

A person is physically qualified to drive a commercial motor vehicle if that person does not use any drug or substance identiied in 21 CFR 1308.ll, Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. A driver may use a non-schedule I drug or substance that is identiied in the other Schedules in 21 part 1308 if the substance or drug is prescribed by a licensed medical practitioner who: (A) is familiar with the driver’s medical history,and assigned duties,and

(B)has advised the driver that the prescribed substance or drug will not adversely affect the driver’s ability to safely operate a commercial motor vehicle.

This exception does not apply to methadone. The intent of the medical certiication process is to medically evaluate a driver to ensure that the driver has no medical condition which interferes with the safe performance of driving tasks on a public road. If a driver uses a Schedule I drug or other substance, an amphetamine, a narcotic or any other habit-forming drug, it may be cause for the driver to be found medically unqualiied. Motor carriers are encouraged to obtain a practitioner’s written statement about the effects on transportation safety of the use of a particular drug.

A test for controlled substances is not required as part of this biennial certification process. The FMCSA or the driver’s employer should be contacted directly for information on controlled substances and alcohol testing under Part 382 of the FMCSRs.

The term “uses” is designed to encompass instances of prohibited drug use determined by a physician through established medical means.

This may or may not involve body luid testing. If body luid testing takes place, positive test results should be conirmed by a second test of greater speciicity. The term “habit-forming” is intended to include any drug or medication generally recognized as capable of becoming habitual, and which may impair the user’s ability to operate a commercial motor vehicle safely.

The driver is medically unqualiied for the duration of the prohibited drug(s) use and until a second examination shows the driver is free from the prohibited drug(s) use. Recertiication may involve a substance abuse evaluation, the successful completion of a drug rehabilitation program, and negative drug test result.Additionally, given that the certiication period is normally two years, the examiner has the option to certify for a period of less than 2 years if this examiner determines more frequent monitoring is required. (See Conference on Neurological Disorders and Commercial Drivers and Conference on Psychiatric Disorders and Commercial Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

alcoholism §391.41(b)(13)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no current clinical diagnosis of alcoholism. The term “current clinical diagnosis of” is speciically designed to encompass a current alcoholic illness or those instances where the individual’s physical condition has not fully stabilized, regardless of the time element. If an individual shows signs of having an alcohol- use problem, he or she should be referred to a specialist. After counseling and/or treatment, he

or she may be considered for certiication.

yes no

Any illness or injury in last 5 years

Head/Brain injuries, disorders or illnesses

Seizures, epilepsy

medication ____________________

Eye disorders or impaired vision (except corrective lenses)

Ear disorders, loss of hearing or balance

Heart disease or heart attack, other cardiovascular condition

medication ____________________

Heart surgery (valve replacement/ bypass, angioplasty, pacemaker) High blood pressure

medication ____________________

Muscular disease

yes no

Shortness of breath

Lung disease, emphysema, asthma, chronic bronchitis

Kidney disease, dialysis

Liver disease

Digestive problems

Diabetes or elevated blood sugar controlled by:

diet

pills

insulin

Nervous or psychiatric disorders, e.g., severe depression

medication ____________________

Loss of, or altered consciousness

yes no

Fainting, dizziness

Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

Stroke or paralysis

Missing or impaired hand, arm, foot, leg, inger, toe

Spinal injury or disease

Chronic low back pain

Regular, frequent alcohol use Narcotic or habit forming drug use

DRIVER’S SIGNATURE

DATE

M M D D y y y y

Page 1 of 4

DRIVER LICENSE NUMBER

NAME

DATE OF EXAM

7. PhysiCal eXaMination

HEIGHT

IN.

WEIGHT

LBS

DRIVER’S IDENTITY VERIFIED BY:

DATE OF EXAM