Commercial Driver Medical Examiner

Transcription

Commercial Driver Medical Examiner
Training: Improving Transportation Safety
through Education and Certification
2015
© Mayo
Foundation for Medical Education and Research
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ii
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Copyright ©2001-2015 Mayo Foundation for Medical Education and Research. All rights reserved.
iii
Table of Contents
CME Activity Description ............................................................................................................................ v
CME Activity Objectives .............................................................................................................................. v
Intended Audience ........................................................................................................................................ v
Continuing Education Credit ....................................................................................................................... vi
CME Record of Attendance ......................................................................................................................... vi
CME Activity Evaluation ............................................................................................................................ vi
Syllabus and Internet Access ...................................................................................................................... vii
Recording Device Policy ............................................................................................................................ vii
Electronic Devices ...................................................................................................................................... vii
Faculty ....................................................................................................................................................... viii
Faculty and Provider Disclosure Summary ................................................................................................. ix
Program Schedule ......................................................................................................................................... x
Presentations ................................................................................ See Program Schedule for Page Numbers
Resources .................................................................................................................................................. 139
Form 649-F ............................................................................................................................................... 197
Certificate for Drivers ............................................................................................................................... 205
iv
CME Activity Description
Committed to improving transportation safety through education and certification, Mayo Clinic offers inperson training for health care professionals who perform physical examinations for Commercial Motor
Vehicle (CMV) drivers. Effective May 21, 2014, all health care professionals who perform physical
examinations and issue medical certificates for CMV drivers will be required to complete accredited
certification training and pass an examination.
This interactive course will provide the essential core administrative and clinical knowledge necessary to
complete the required examination mandated by the Federal Motor Carrier Safety Administration
(FMCSA). This course will review certain subspecialty diseases and conditions encountered while
performing CMV examinations, utilizing a case-based interactive approach focused on efficiently
addressing complex clinical issues. Participants will have the opportunity to experience the physical
demands associated with operating a large commercial vehicle with a semi-trailer at the course site.
The training includes the following core competencies:
 The examiner’s role in enhancing public safety
 Diagnostic approaches in assessing medical fitness of the commercial driver
 Navigating clinical and administrative issues commonly encountered in driver medical
certification
 Understanding and effectively managing the complexity of the physical requirements and stresses
involved in operating commercial vehicles
 Strategies for prevention and health promotion for CMV drivers
Content will focus on the core curriculum required by the FMCSA. Following completion of this training,
participants will receive the certification required to take the NRCME examination.
CME Activity Objectives
Upon conclusion of this program, participants should be able to:







Describe the specific physical and mental demands associated with operating a commercial motor
vehicle (CMV).
Understand the responsibilities of a CMV driver.
Recognize potentially disqualifying diseases, medications, or health conditions in the examination
process, and provide drivers with parameters for safely proceeding with work duties.
Document the requirements for the medical history and physical examination of a CMV operator.
Develop strategies for efficiently conducting forensic evaluations, including addressing difficult
issues in the certification process.
Discuss a variety of strategies for promoting improved health and wellness in this cohort of
individuals.
Understand step-by-step process of registering for FMCSA exam and NRCME registry.
Attendance at this Mayo Clinic activity does not indicate nor guarantee competence or proficiency in the
performance of any procedures which may be discussed or taught in this activity.
Intended Audience
This program is designed for health care professionals who will be performing DOT examinations, or
who have an interest in promoting wellness in the population of professional drivers.
v
Continuing Education Credit
Mayo Clinic College of Medicine is accredited by the Accreditation Council for Continuing Medical
Education to provide continuing medical education for physicians.
Mayo Clinic College of Medicine designates this live activity for a maximum of 7.5 AMA PRA Category
1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation
in the activity.
This Live activity, Commercial Driver Medical Examiner Training: Improving Transportation Safety
through Education and Certification, from 03/28/2015 - 11/07/2015, has been reviewed and is acceptable
for up to 7.50 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should
claim only the credit commensurate with the extent of their participation in the activity
This activity was approved by the American Board of Preventive Medicine for Maintenance of
Certification (MOC) credit for a maximum of 7.5 LLSA/MOC credits.
This physician board credit can only be granted following completion of the pre-test, course activity, and
post-test. ABPM diplomate number will be required for successful upload to ABPM.
CME Record of Attendance
A Record of Attendance is provided to you during on-site registration. The Record of Attendance allows
attendees to calculate their own credits of participation in the educational activity.
The total number of credits participants can earn per day is noted on the Record of Attendance. Below
each day is a line to record the actual number of credits during which you participated in the educational
activity. It is recommended that you record your actual credits daily as you proceed through the CME
activity.
Upon conclusion of the CME activity, please total the number of credits you have recorded on the top half
of the form, sign it, and return it with your evaluation to the registration desk.
The bottom half of the form represents your Record of Attendance, which you must retain for your
records. Please make sure the number of credits claimed in both sections coincide. No other
documentation is provided to you after this CME activity. The Record of Attendance has replaced the
certificate.
The Record of Attendance can be used for requesting credits in accordance with state licensing boards,
specialty societies, or other professional associations.
CME Activity Evaluation
The overall CME activity evaluation will be emailed following the activity to the email address that was
provided when you registered. The CME activity evaluation is brief and will only take a few minutes to
complete.
Faculty evaluation forms were offered to a sampling of the registrants. Completed faculty evaluation
forms should be returned to the registration desk at the conclusion of the CME activity. If you wish to
participate in evaluating the faculty, please stop at the registration desk to inquire if extra evaluation
forms are available.
vi
Your feedback is very important to us and will be used for planning future programs, as well as
identifying faculty strengths and opportunity for growth.
Syllabus and Internet Access
An electronic syllabus will be provided to all attendees. Participants are invited to bring their laptops to
the meeting room(s). Due to copyright issues or revisions, some slides may be shown during a
presentation, but not provided within the syllabus.
Recording Device Policy
No recording devices, audio or visual, may be used during Mayo Clinic College of Medicine CPD
activities. Duplication, distribution, or excerpting of this program, without the express written permission
of Mayo Clinic, is strictly prohibited.
All of the proceedings of this program, including the presentation of scientific papers, are intended for
limited publication only, and all property rights in the material presented, including common-law
copyright, are expressly reserved by the Faculty and/or Mayo Clinic. No statement of presentation made
is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the
material presented at this CME activity without the permission of Mayo Clinic is prohibited to the full
extent of common-law copyright in such material.
Electronic Devices
Please turn all electronic devices (cellular telephones, pagers, etc.) to silent mode. As a courtesy to the
presenters and other participants, phone calls should be taken outside of the general session.
vii
Faculty
Course Director
Clayton T. Cowl, M.D., M.S.
Mayo Clinic Associate Professor of Medicine
Division of Preventive, Occupational, and Aerospace Medicine
Division of Pulmonary & Critical Care Medicine
Mayo Clinic
Cindy M. Boyum, R.N., C.N.P.
Department of Family Medicine
Debra K. McCauley, R.N., C.N.P.
Steven M. Bruce, M.D.
Instructor in Family Medicine
Robin G. Molella, M.D.
Instructor in Preventive Medicine
Division of Preventive, Occupational,
and Aerospace Medicine
William G. Buchta, M.D.
Darryl S. Chutka, M.D.
Associate Professor of Medicine
Executive Health Program
Associate Dean, Mayo School of
Continuous Professional Development
Sarah J. Crane, M.D.
Assistant Professor of Medicine
Division of Primary Care Internal Medicine
Philip T. Hagen, M.D.
Terry W. Kuhlwein, M.D.
Instructor of Family Medicine
Occupational Medicine
Richard D. Newcomb, M.D.
Cheryl L. Pietila, R.N., C.N.P.
Mark W. Steffen, M.D.
Debra Thompson, R.N., F.N.P.-C., C.N.P.
Mayo Clinic Health System – Mankato
Department of Occupational Medicine
Barbara J. Timm, R.N., C.N.P.
John M. Wilkinson, M.D.
James M. Lance, D.O., M.P.H.
Instructor of Family Medicine
Occupational Medicine
Program Faculty
viii
Faculty, Planning Committee and Provider Disclosure
Summary
Commercial Driver Medical Examiner Training:
Improving Transportation Safety through Education and Certification
As a provider accredited by ACCME, College of Medicine, Mayo Clinic (Mayo School of CPD) must
ensure balance, independence, objectivity and scientific rigor in its educational activities. Course
Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the
content of this educational activity are required to disclose all relevant financial relationships with any
commercial interest related to the subject matter of the educational activity. Safeguards against
commercial bias have been put in place. Faculty also will disclose any off label and/or investigational use
of pharmaceuticals or instruments discussed in their presentation. Disclosure of these relevant financial
relationships will be published in activity materials so those participants in the activity may formulate
their own judgments regarding the presentation.
Listed below are individuals with control of the content of this program who have disclosed…
Relevant financial relationship(s) with industry:
Name
None
Nature of Relationship
Company
No relevant financial relationship(s) with industry:
Name
Cindy M. Boyum, R.N., C.N.P.
James M. Lance, D.O., M.P.H.
Steven M. Bruce, M.D.
Debra K. McCauley, R.N., C.N.P.
William G. Buchta, M.D.
Robin G. Molella, M.D.
Darryl S. Chutka, M.D.
Richard D. Newcomb, M.D.
Clayton T. Cowl, M.D., M.S.
Cheryl L. Pietila, R.N., C.N.P.
Sarah J. Crane, M.D.
Mark W. Steffen, M.D.
Kathy Fuqua
Debra Thompson, R.N., F.N.P.-C, C.N.P.
Philip T. Hagen, M.D.
Barbara J. Timm, R.N., C.N.P.
Terry W. Kuhlwein, M.D.
John M. Wilkinson, M.D.
References to off-label and/or investigational usage(s) of pharmaceuticals or instruments in
their presentation:
Name
None
Manufacturer/Provider
ix
Product/Device
Program Schedule
Commercial Driver Medical Examiner Training:
Improving Transportation Safety through Education and Certification
2015 Courses
7:30 a.m.
Registration and Refreshments
8:00 a.m.
Session 1: The Examiner’s Role in Enhancing Public Safety (includes 15-minute break) ............................. 12
10:00 a.m.
Session 2: Diagnostic Approaches in Assessing Medical Fitness of the Commercial Driver ......................... 38
12:00 p.m.
Lunch – Boxed Lunch Provided
1:00 p.m.
Session 3: Navigating Clinical Issues in Driver Medical Certification ............................................................. 70
2:30 p.m.
Refreshment Break
2:45 p.m.
Session 4: Making the Forensic Determination................................................................................................ 112
4:00 p.m.
Session 5: National Registry Signup & Exam Preparation .............................................................................. 125
5:00 p.m.
Adjourn
The Examiner’s Role in Enhancing Public Safety
 Overview of FMCSA Initiatives and Programmatic Structure
 Epidemiologic Data on Commercial Motor Vehicle Highway Safety
 Form Completion and Documentation (including Laboratory and Office Based Diagnostic Testing
 Understanding Workplace Stressors in the Driving Environment
 Hands-on Primer on How a Truck Works (Parking Lot)
Diagnostic Approaches in Assessing Medical Fitness of the Commercial Driver
 Strategies for Targeted History Taking and Efficient Physical Examinations
 Overview of Non-Discretionary Disqualifying Conditions
 Organ System Based Review of Commonly Encountered Medical Conditions
o Vision
o Auditory Acuity
o Diabetes Mellitus and Endocrine Disorders
o Hypertension
Navigating Clinical Issues in Driver Medical Certification
 Organ System Based Review of Commonly Encountered Medical Conditions (Cont.)
o Cardiovascular
o Respiratory (Including Sleep-Related Disordered Breathing)
o Neurological
o Substance Abuse and Medication Use
Making the Forensic Determination
 The Role of Prevention and Counseling in Driver Cohorts
 Judging Recertification Intervals
 Interactive Review of Case Examples
 Review of Electronic Resources for Course
National Registry Signup & Exam Preparation
 Specific Directions on Registry Signup & Exam Preparation
 How to Register for the FMCSA Medical Examiner Test
 Review of Electronic Resources from Course to Use in Practice
x
Let’s Roll!
Welcome to the Mayo Clinic course on
Commercial
Driver
Medical
Examiner
Training! My colleagues and I have been
working to provide every attendee a valuable
experience packed full of useful kernels of
clinical knowledge combined with the
opportunity to learn more about trucks, the
trucking industry, and the multiple stressors
that affect the drivers who we examine.
It is impossible to cover every topic of
commercial motor vehicle examination
training in a one-day course, and no
educational platform can replace the clinical
knowledge base and efficiencies learned
through years of experience in performing
these examinations on a regular basis.
However, our desire is to deliver a very
efficient platform for each of you to learn the
essentials of completing these examinations,
and to provide an “electronic toolbox” for your
use over time as a reliable resource.
This course will meet the key curriculum
requirements outlined by the Federal Motor
Carrier Safety Administration (FMCSA) and
assist you in passing the examination
required to become a valid provider in its
National Registry of Certified Medical
Examiners (NRCME). This includes coverage
of administrative details involved in the
oversight of examinations, information on how
to correctly complete medical application
forms, and clinical pearls in completing the
physical examination and how to make a
certification determination. This learning
activity is not intended to be a primary tool for
providers to learn how to perform a physical
examination or how to master the basics of
history-taking and diagnosis as it is assumed
that participants are appropriately licensed to
practice medicine or chiropractic care in their
respective states or jurisdictions and will have
already completed training in these areas.
This course will focus on skills required for
participants to perform commercial driver
medical examinations efficiently. But more
importantly, our goal is for each of you to
come away with an appreciation of what
drivers face in their occupations, and
recognize the lifestyle issues that lead to
unacceptable levels of obesity, tobacco abuse,
hypertension, diabetes, coronary artery
disease,
and
sleep-related
disordered
breathing such as sleep apnea. Together, we
as a medical profession can make important
contributions to improving the health of the
people who transport the very materials we all
use on a daily basis and with whom we share
the roads.
Thanks so much for trusting us here at Mayo
Clinic with the opportunity to share this
material, and I look forward to our continuing
interactions in the future!
Clayton T. Cowl, MD, MS
Course Director
Commercial Driver Medical
Examiner Training:
Improving Transportation Safety
through
Education and Certification
Session 1
Live Course
©2014 MFMER | 3212718-1
The Examiner’s Role in Enhancing Public Safety
©2014 MFMER | 3212718-2
I am a current DOT Medical Examiner.
1. Yes
2. No
0%
0%
1
2
©2012 MFMER | 3212718-3
I am which of the following types of health
care providers…
1.
2.
3.
4.
Medical Doctor
Osteopathic Physician
Chiropractor
Advanced Practice
Nurse
5. Physician Assistant
0%
1
0%
2
0%
0%
3
4
0%
5
©2012 MFMER | 3212718-4
My gender is:
1. Male
2. Female
0%
0%
1
2
©2012 MFMER | 3212718-5
My main practice location is in…..
1.
2.
3.
4.
5.
6.
7.
Minnesota
Wisconsin
North Dakota
South Dakota
Iowa
Illinois
Other
0%
1
0%
0%
0%
2
3
4
0%
0%
5
6
©2012 MFMER | 3212718-6
©2014 MFMER | 3212718-7
What are the FMCSA core curriculum topics?
• Background, rationale, mission, and Medical
Examiner’s role
FMCSA
Federal Motor Carrier Safety Administration
• Commercial Motor Vehicle (CMV) driver’s
responsibilities and work
©2014 MFMER | 3212718-8
• CMV driver identification and medical history
• Obtaining, reviewing, and documenting
• Prescription and over-the-counter medications
©2014 MFMER | 3212718-9
• Performing and documenting the Medical Examination
©2014 MFMER | 3212718-10
• Additional diagnostic tests or medical opinions, as needed
• Performing, obtaining, and documenting diagnostic tests
• Obtaining medical specialist/treating physician opinion
©2014 MFMER | 3212718-11
• Inform/educate CMV driver
• Medications and/or non-disqualifying medical conditions needing
care
©2014 MFMER | 3212718-12
• Determining driver certification outcome (including period for which
certification is valid)
• FMCSA reporting and documentation requirements
©2014 MFMER | 3212718-13
(FMCSA)
• Was created with the signing of the Motor
Carrier Safety Improvement Act of 1999 by
President Clinton
• The FMCSA evolved from the Federal Highway
Administration
• Is one of several administrations and agencies
housed under the Department of Transportation
• Headquarters in Washington DC
©2014 MFMER | 3212718-14
FMCSA
Mission:
“Focused on reducing
crashes, injuries, and
fatalities involving large
trucks and buses.”
• Attempt to establish regulations that balance safety with industry
efficiency using objective data
• Utilize a systems approach to target higher-risk motor carriers
• Develops educational messages to carriers, commercial drivers and
the public
• Partners with Federal, State, and local agencies, the motor carrier
industry, safety groups, and organized labor to target reduction of
bus and truck-related crashes
©2014 MFMER | 3212718-15
FMCSA
Organizational Framework
Focused on Medical
Guidelines and
Standards
©2014 MFMER | 3212718-16
FMCSA
Office of Medical Programs
• Oversees national medical certification process for CMV
drivers in interstate commerce
• Develops and reviews medical regulations, policies and
procedures
• Responsible for the national registry of medical examiners
program and a national driver medical reporting system
• Recruits, oversees and supports the Medical Review Board
(MRB) as dictated by the Federal Advisory Committee Act as
well as Medical Expert Panels (MEPs)
• Leads the medical exemption and certification programs
• Guides efforts to conduct medical research in the areas of
CMV driver health and safety trends
©2014 MFMER | 3212718-17
FMCSA
Office of Analysis, Research & Technology
• Produces reports analyzing prevalence of fatalities
and serious injuries, trends, and costs involving
large truck and bus crashes
• Objective data collated by this office is used to
direct efforts to minimize accidents and injuries, and
to attenuate the severity of accidents when they do
occur
• Involved in generating all economic and
environmental data used for federal rulemaking
• Makes statistical data easily accessible to the
public
©2014 MFMER | 3212718-18
The FMCSA continually reviews medical
standards and guidelines
• Agency expert analyses of federal data and other
relevant international, national, and state data
• Interagency, national, and international regulatory
analyses
• Evidence reports
• Medical Expert Panels (MEPs)
• Medical Review Board (MRB) -- a committee
established in accordance with the Federal
Advisory Committee Act
©2014 MFMER | 3212718-19
Medical guidelines and MEP opinions
• Posted on the FMCSA website
• MRB meets 3-4 times per year on specific topics
• MRB independently reviews evidence reports and if
a MEP was convened, also reviews MEP opinion.
The MRB deliberates and proposes
recommendations for consideration by FMCSA
• MRB proceedings and public meetings are also
posted on an internet-based format
• New standards require a Notice of Proposed Rule
Making and publication in the Federal Register
©2014 MFMER | 3212718-20
What organization is responsible for
developing and maintaining the NRCME?
1. State DOT office
2. Office of the Assistant
Administrator (Chief
Safety Officer)
3. Office of Medical
Programs
4. Office of Analysis,
Research & Technology
0%
0%
0%
2
3
1
0%
4
©2012 MFMER | 3212718-21
All of the following statements are correct
EXCEPT:
1.
2.
3.
4.
The Medical Expert Panel
(MEP) provides opinions on
specific medical conditions.
The Medical Review Board
reviews and is required to
implement MEP opinions.
Any new standard must
complete a full public review
process.
All MRB and MEP reports and
actions are posted on the
FMCSA web site.
0%
1
0%
0%
2
3
0%
4
©2012 MFMER | 3212718-22
Commercial Motor Vehicle Crashes
• Occupants of lighter
vehicles often sustain
much more severe
injuries
• Injury severity is
directly proportional
to mass and its
corresponding
velocity changes
• Heavier vehicles such
as large trucks and
buses are many
times the weight of
smaller passenger
vehicles
©2014 MFMER | 3212718-23
Large Truck Accident Prevalence is High
• In 2010 more than 500,000 Large
Truck and Commercial Vehicles
were involved in accidents
• More than 100,000 people
sustained serious injuries, and
more than 5000 people died in
these crashes
• More than 20% more CMVs are
expected to hit the roads by
2016*
∗data from the Insurance Institute for Highway Safety
©2014 MFMER | 3212718-24
Which of the following statements are true?
1.
2.
3.
4.
More than 100,000 people sustained
injuries involving large trucks in 2010.
CSA stands for, “Compliance, Service
and Action.”
In CMV accidents, almost twice as
many deaths involved drivers of large
trucks as compared to drivers of
SUVs.
Because of new regulations, it is
anticipated that 20% fewer commercial
motor vehicles will be on the road by
2014.
0%
1
0%
0%
2
3
0%
4
©2012 MFMER | 3212718-25
Title 49
“FMCSA, Department of Transportation”
Part 391
Code of Federal Regulations
• These are legal regulations – not
guidelines
Medical Guidelines or Advisory Criteria
• Based upon expert review and considered
best practice
• ME may or may not choose to use these
recommendations, but reason for not
following guidelines should be clearly
explained in their documentation
Section 41
Subpart E
“Physical Qualifications and
Examinations”
49 CFR 391.41
©2014 MFMER | 3212718-26
The federal statute that outlines the
physical requirements for a CMV driver is:
1.
2.
3.
4.
49 CFR 391.45
FAR 61.53
49 CFR 391.47
49 CFR 391.41
0%
1
0%
0%
2
3
0%
4
©2012 MFMER | 3212718-27
Regulation
49 CFR 391.41
49 CFR 391.43
Description
Describes the physical qualification requirements for drivers. The 13 standards are used to determine driver
medical fitness for duty. Four of the standards: vision, hearing, epilepsy, and diabetes mellitus have objective
disqualifiers that do not depend on medical examiner clinical interpretation. These standards are the "nondiscretionary" standards. For the other nine "discretionary" standards, the medical examiner makes a clinical
judgment in accordance with the physical qualification requirements for driver certification.
Describes the responsibilities of the medical examiner, including general instructions for performing the
medical examination, a description of driver tasks and work environment, medical advisory criteria, the
sample Medical Examination Report form, and the medical examiner's certificate.
Identifies who must have the commercial motor vehicle (CMV) driver physical examination.
49 CFR 391.45
49 CFR 391.47
49 CFR 391.49
49 CFR 391.62
49 CFR 391.64
49 CFR 390
49 CFR 40
Describes the process for conflict resolution when there is a disagreement between the primary care
provider for the driver and the medical examiner for the motor carrier concerning driver qualifications.
Describes the Skill Performance Evaluation (SPE) Certification Program, which is an alternative physical
qualification standard for the driver with a fixed musculoskeletal deficit of an extremity who cannot physically
qualify to drive under §391.41(b)(1) or (b)(2). The driver must be otherwise qualified to drive a CMV and meet
the provisions of the alternate standard. The first program to address fixed musculoskeletal deficits was created
and administered by the Interstate Commerce Commission (ICC) in 1964 and was known as the Handicapped
Driver Waiver Program.
Describes limited exemptions for intra-city zone drivers.
Describes grandfathering for certain drivers who participated in vision and diabetes waiver study programs.
These drivers may be certified as long as they continue to meet the provisions outlined in 49 CFR 391.64
and continue to meet all other qualification standards.
Includes general information and definitions.
Includes regulations for medical review officers and substance abuse professionals (SAPs), including drug
and alcohol testing procedures.
©2014 MFMER | 3212718-28
Who
Must be certified?
©2014 MFMER | 3212718-29
Literally millions of drivers require
evaluation
• Estimated 6-9 million
CMV drivers must comply
with FMCSA physical
standards
• The FMCSA estimates
that there will need to be
3-5 million medical
examinations each year
• Shortages of drivers are
being realized
©2014 MFMER | 3212718-30
What is the typical driver profile?**
• Male
• >40 years of age
• Sedentary
• Overweight
• Tobacco abuse
Medically:
• Less healthy than the
average person
• > 2 medical conditions
• Prevalent cardiovascular
disease
• Higher rates of sleep apnea
• Poor eating habits
** from FMCSA data
©2014 MFMER | 3212718-31
What
Is a commercial motor
vehicle?
©2014 MFMER | 3212718-32
Commercial Motor Vehicle
• Any self-propelled or towed motor vehicle used on a highway in
interstate commerce to transport passengers or property when the
vehicle:
• Has a gross vehicle weight rating or gross combination weight
rating, of 4,536 kg (10,001 pounds) or more, whichever is greater;
or
• Is designed or used to transport more than 8 passengers (including
the driver) for compensation; or
• Is designed or used to transport more than 15 passengers,
including the driver, and is not used to transport passengers for
compensation; or
• Is used in transporting material found by the Secretary of
Transportation to be hazardous under 49 U.S.C. 5103 and
transported in a quantity requiring placarding under regulations
prescribed by the Secretary under 49 CFR, subtitle B, chapter I,
subchapter C.
©2014 MFMER | 3212718-33
Interstate Commerce
• Commerce means (a) any trade, traffic or transportation
within the jurisdiction of the United States between a
place in a State and a place outside of such State,
including a place outside of the United States and (b)
trade, traffic, and transportation in the United States
which affects any trade, traffic, and transportation
described in paragraph (a) of this definition.
• Drivers not subject to Federal regulations and
participate solely in intrastate commerce are regulated
by the State
• Medical examiners are responsible for knowing the
requirements within the state they are practicing
©2014 MFMER | 3212718-34
Commercial Motor Vehicles
Come in all shapes and sizes
©2014 MFMER | 3212718-35
Commercial Motor Carrier
• Motor carrier means a for-hire motor carrier
or a private motor carrier.
• The term includes a motor carrier's agents,
officers and representatives as well as
employees responsible for hiring,
supervising, training, assigning, or
dispatching of drivers and employees
concerned with the installation, inspection,
and maintenance of motor vehicle equipment
and/or accessories.
©2014 MFMER | 3212718-36
Commercial Motor Carrier
• The motor carrier must ensure that its drivers meet the standards outlined
in 49 CFR 391.11 -• Driver must be at least 21 years of age
• Comprehend and use the English language
• Must safely operate a commercial vehicle
• Have only one valid CMV operator’s license
• Current medical certificate must be on file (some request “long form”)
• Collect appropriate background check and violation records from
driver (as described in 391.27)
• Have completed a driver’s road test
• Not currently disqualified to drive a CMV
• Motor Carrier may impose other requirements such as minimum lifting
capability
©2014 MFMER | 3212718-37
Forms
What should you know?
©2014 MFMER | 3212718-38
Form Completion (649-F)
• First, identify the driver
• Use appropriate Medical Examination Report form;
• Assure that driver completes and signs driver’s portion
of the Medical Examination Report form;
• Review in detail any specifics regarding any affirmative
response on the driver’s medical history;
©2012 MFMER | 3212718-39
Health History
• Driver must include lifetime history
• Any “YES” answer should be clarified below
• May add data onto separate page that is signed
and dated
©2012 MFMER | 3212718-40
Make sure to include:
• Height/weight, blood pressure, pulse;
• Details of abnormal findings;
• Audiometric and vision testing results;
• Presence or absence of a hearing aid and
whether it is required to meet the standard;
• If obtained, funduscopic examination results;
• Document the need for corrective lenses for
driving;
• Indicate presence or absence of monocular
vision and need for a vision exemption;
©2014 MFMER | 3212718-41
Make sure to include:
• If driver has diabetes mellitus and is insulin
dependent, the need for a diabetes exemption;
• Document results of other laboratory,
pulmonary, cardiac testing performed; and
outline the reason(s) for the disqualification
and/or referral (if pertinent).
• Form should be completed in full (and as legible
as possible)
• Forms need to be secured by ME for 3 years
• Form may be electronic but need to have ability
to print all data on hard copy and present a
medical card to driver
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Physical Examination
©2014 MFMER | 3212718-43
• Driver must certify all responses are not falsified
and that the form is complete
• An incomplete, misleading, or falsified form will
invalidate the exam and resulting certificate
• Criminal and/or civil action may be pursued
against the driver for false statements or failure
to report a disqualifying condition
©2014 MFMER | 3212718-44
Medical Examiner Certificate
Medical Examiner’s Certificate
(Make sure you have new
format with line to include
NRCME number)
Form 649-F “Long Form” includes all pages and
supplemental attachments (e.g. test results)
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What
Stressors do drivers
encounter?
©2014 MFMER | 3212718-46
Driving stressors are magnified by multiple factors
• Erratic schedules
• Environmental factors
• Types of cargo
• Driving exposure is extensive
and involves many tasks
•
•
•
•
•
•
•
•
•
Alertness
Use of spatial orientation
Steering wheel control
Gear shifting
Manipulate dashboard switches
and controls
Enter and exit the vehicle
Load, secure, and unload cargo
Perform vehicle inspections
Coupling and uncoupling trailers
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Types of
Driving
Routes
Turn-around or
Short Relay
Long-Relay or
Regional
Straight through
haul
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Basic Parts of the Truck
Exhaust
stack
Fifth Wheel
Glad Hands
Kingpin
Landing Gear
Mud Guard
©2014 MFMER | 3212718-49
The federal statute that outlines the
physical requirements for a CMV driver is:
1.
2.
3.
4.
49 CFR 391.45
FAR 61.53
49 CFR 391.47
49 CFR 391.41
0%
1
0%
0%
2
3
0%
4
©2012 MFMER | 3212718-50
Tasks requiring intact musculoskeletal
system
• Climb into and out of the truck
• Manipulating the steering wheel
• Shifting gears
• Maintaining pressure on pedals/braking
• Performing pre and post safety checks
• Ensuring the vehicle is loaded properly
• Securing the load
• Evaluating and managing vehicle breakdowns
• Responding to weather or emergency situations
©2014 MFMER | 3212718-51
Examiner Training:
through
Session 2
©2014 MFMER | 3212718-1
Session 2
Diagnostic Approaches in Assessing
Medical Fitness of the Commercial
Driver
• Strategies for Targeted History Taking and
Efficient Physical Examinations
• Overview of Non-discretionary Disqualifying
Conditions
• Organ System-based Review of Commonly
Encountered Medical Conditions
©2014 MFMER | 3212718-2
In my practice I exam about _____ CMV
drivers each year.
1.
2.
3.
4.
5.
<10
10-20
20-50
50-100
>100
0%
0%
1
2
0%
0%
3
4
0%
5
©2012 MFMER | 3212718-3
Of the drivers I evaluate, the estimated
number who are issued 2-year
certifications is:
1.
2.
3.
4.
5.
6.
<10%
10-25%
25-50%
50-75%
75-90%
>90%
0%
1
0%
2
0%
0%
0%
3
4
5
0%
6
©2012 MFMER | 3212718-4
Physical examination
• Opportunity to re-review health history
• You can examine in “parallel,” not “series”
• You cannot examine what you cannot see -the patient needs to disrobe and gown up
• Creating an environment conducive to a good
exam is very important (i.e. control background
ambient noise, have professional setting, etc.)
©2014 MFMER | 3212718-5
Physical Examination Video
©2014 MFMER | 3212718-6
The “Final Four”
Visual acuity
Hearing acuity
<20/40
<70º field of vision
Color vision loss
Monocular vision
Whispered voice test
and audiometry
Epilepsy
Diabetes
requiring insulin
Non-discretionary standards that preclude driver certification
©2014 MFMER | 3212718-7
Which of the following conditions would be
considered “non-discretionary” conditions
resulting in medical disqualification of the
commercial driver if present on exam?
1. Coarctation of the
aorta
2. Vertigo
3. 2 unexplained
seizures in prior 3
years
4. Type II diabetes
5. Stage I Hypertension
0%
1
0%
2
0%
0%
3
4
0%
5
©2012 MFMER | 3212718-8
Vision
Requirements:
• Distant vision 20/40
(Snellen) in each eye
separately and concurrently
with or without correction
• Field of vision of at least 70º
in the horizontal median for
each eye
• Ability to recognize the
colors of traffic signals and
devices showing red, green,
and amber
©2014 MFMER | 3212718-9
Vision
• If corrective lenses
required to meet
standard, those lenses
must be worn while
driving
• Optometrist,
ophthalmologist, or
ME/designate may
perform testing but ME
makes final certification
determination
• Monocular vision is
considered disqualifying
but may be acceptable
for exemption
©2014 MFMER | 3212718-10
Visual acuity
• Visual perception may be
challenging due to extended
exposure at the wheel, need
for spatial orientation, use of
mirrors, long turning radius,
presence of blind spots,
extended stopping times
• History should include
questions regarding
medication for eye disorders
• May use any variety of types of
charts that measure acuity or
an alternative visual acuity
measurement device
©2014 MFMER | 3212718-11
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Key History Points:
• Current over-the-counter (OTC) and prescription medications or supplements
including potential side effects.
• Eye disorders and/or family history of eye disorders (e.g. monocular vision,
retinopathy, cataracts, glaucoma, strabismus, macular degeneration)
• Corrective lens (contacts or glasses); accommodation for color blindness
• Past medical history in addition to eye disorders including diabetes,
hypertension, thyroid disorders.
• Exposures to direct sun exposure, smoking, trauma from recreational activities;
sports or hunting.
©2014 MFMER | 3212718-16
Eye abnormalities to screen and
discuss with driver
• Cataracts
• Aphakia
• Nystagmus
• Ocular muscle
imbalance
• Glaucoma
• Macular
Degeneration
• Retinopathy
©2014 MFMER | 3212718-17
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©2014 MFMER | 3212718-20
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Phoria Testing
Phoria exams test the natural position of the eyes. If you have a
normal visual system, both eyes point the same direction. There are
two factors that make this happen -- the attachment of the six
muscles to the eye; and the brain’s ability to force the eyes to work
together to see one image. During a phoria test, the second factor is
eliminated.
©2014 MFMER | 3212718-22
Strabismus
• Also known as squint, lazy eye and heterotropia is a condition in which the
eyes are not properly aligned with each other. It typically involves a lack of
coordination between the extraocular muscles, which prevents bringing the
gaze of each eye to the same point in space and thus hampers proper
binocular vision, and which may adversely affect depth perception.
Amblyopia
• Also known as lazy eye, is an eye disorder characterized by an impaired vision
in an eye that otherwise appears normal, or out of proportion to associated
structural abnormalities of the eye. In amblyopia, visual stimulation either fails
to transmit or is poorly transmitted through the optic nerve to the brain for a
continuous period of time. It can also occur when the brain "turns off" the visual
processing of one eye to prevent double-vision, for example in strabismus
(crossed-eyes). It often occurs during early childhood, resulting in poor or blurry
vision. Amblyopia normally affects only one eye in most patients.
©2014 MFMER | 3212718-23
Federal Vision Exemption Program
• Used for monocular vision
• Driver must be fully qualified under 49 CFR
391.41(b)(1-13) in order to be eligible for
exemption
• Must have annual medical examination
• Eye evaluation from ophthalmologist and/or
optometrist
• Motor carrier must make sure driver has
required certification prior to operating CMV
©2014 MFMER | 3212718-24
Billy Jo Driver
X
Vision
William A. Feelgood
Bill Feelgood, DO
13275
507-555-1234
10/27/2013
X
MN
1234567812
Billy Jo Driver
P345762348901
X
X
MN
123 Lazy Lane; Rochester, MN 55905
10/27/2014
©2014 MFMER | 3212718-25
….Qualified by Operation of 49 CFR 391.64
aka the “Federal Vision Exemption
Grandfathering” Program
• Occurred 1992 to 1996 as a vision study
program
• Total of 2,656 drivers were granted a
participation certificate for monocular vision,
provided the driver remained otherwise qualified
• Driver must bring eye evaluation from specialist
• Maximum certification is one year
©2014 MFMER | 3212718-26
A 39-year-old CMV driver comes to your office. She
has monocular vision from a hunting accident three
months prior but no other abnormalities. She brings a
valid vision exemption form with her. You should…
1. Defer the medical to the
State DOT
2. Issue a 3-month
certificate
3. Issue the certificate with
need for vision
exemption (1-year)
4. Do not issue certificate
0%
1
0%
2
0%
3
0%
4
©2012 MFMER | 3212718-27
• INSERT PHOTO OF EAR EXAM
©2014 MFMER | 3212718-28
Which of the following is CORRECT
regarding voice testing for CMV drivers?
1. Should be done no
more than 5 ft from
driver
2. Should avoid using
sibilants during testing
3. Failure to pass the
whisper test results in
disqualification
4. Conversational voice
must be utilized
0%
1
0%
2
0%
0%
3
4
©2012 MFMER | 3212718-29
Hearing
• Driver must have auditory
acuity that allows,
• Whispered voice > or =
5 feet or….
• Audiometry does not show
average hearing loss > 40
dB at 500 Hz, 1000 Hz,
and 2000 Hz with or
without hearing
amplification device –
calibrated to
ANSI Z24.5 – 1951
• Either test can be utilized
first, and the other is not
required if standard met
• If both tests of hearing
failed, then disqualified
©2014 MFMER | 3212718-30
Hearing
• Whisper Test – the examiner stands at least 5 feet
from the driver
• Each ear is tested individually. The ear being tested is
turned toward the examiner, and the other ear is
covered.
• The examiner should not use sibilants (s-sounding
words or numbers).
Examples of words/letters/numbers that are silibants:
speech sound such as s, z, sh, or zh
Examples of preferred words/letters/numbers to use for the
whisper test (non-silibants):
apple
rainfall
©2014 MFMER | 3212718-31
Remember your audiometric
conversions -- and that averaging
calculation for the three frequencies
must be <40 dB !!
©2014 MFMER | 3212718-32
Patient #1
ANSI scale measurements
Wavelength (Hz)
Sound detection
(dB) – Left ear
Sound detection
(dB) – Right ear
500
20
20
1,000
40
50
2,000
50
55
3,000
70
90
©2014 MFMER | 3212718-33
Would you certify Patient #1?
1. Yes
2. No
0%
1
0%
2
©2014 MFMER | 3212718-34
Yes, certify!
• Left ear is: 20 + 40 + 50 = 110/3 = 36.67
(which is < 40 dB)
• Right ear is: 20 + 50 + 55 = 125/3 = 41.67
Remember: For FMCSA exams, you do NOT care about
any other frequencies but 500, 1000 and 2000 Hz. Any
other frequency given does not get pulled into the
calculation.
Always use the ear with the best acuity for the calculation.
If in ANSI scale, take the average of the three readings –
otherwise convert from ISO to ANSI (-14, -10, -8.5 dB
conversion).
©2014 MFMER | 3212718-35
Patient #2
ANSI scale measurements
Wavelength (Hz)
Sound detection
(dB) – Left ear
Sound detection
(dB) – Right ear
500
10
20
1,000
45
50
2,000
70
55
3,000
35
90
©2014 MFMER | 3212718-36
Would you certify Patient #2?
1. Yes
2. No
0%
0%
1
2
©2014 MFMER | 3212718-37
No, do not certify! (refer for further hearing evaluation)
• Left : 10 + 45 + 70 = 125/3 = 41.67
• Right: 20 + 50 + 55 = 125/3 = 41.67
(does not meet <40 dB standard)
So, the driver would need to be tested with
hearing amplification as recommended by an
audiologist or ENT professional…
©2014 MFMER | 3212718-38
Generally disqualifying otic
conditions
• Vertigo
(uncontrolled)
• Meniere’s Disease
• Labyrinthine
Fistula
• Nonfunctioning
Labyrinth
**Driver should not drive for at least 2 months after Benign
Positional Vertigo or Peripheral Vestibulopathy
©2014 MFMER | 3212718-39
Diabetes mellitus and other Endocrine
Disorders
©2014 MFMER | 3212718-40
Diabetes Mellitus
49 CFR 391.41 (b)(3)
• Driver with insulin-dependent diabetes is
disqualified medically
• More than 23 million people (7.8% of
population) have diabetes – and many more
likely remain undiagnosed
• Type II DM – adult onset
• Can produce insulin and retain many glycemic
control mechanisms
• With progression of disease, may require insulin
• Hypoglycemic detection is the most important aspect
of management for safety purposes
©2014 MFMER | 3212718-41
Lifestyle issues are major determinant
of long-term treatment success
• Elevated glycemic index
(HbA1c)
• Hyperglycemia may lead
to neuropathy,
retinopathy, nephropathy,
PVD, CAD, lethargy,
fatigue
• Hypoglycemia is a critical
safety issue for drivers
that may result in seizure,
impaired cognition, etc.
©2014 MFMER | 3212718-42
Important Health History Questions for
Diabetic Drivers
• Do you use medication to control blood sugars
(including incretin mimetics like Byetta
[exenatide])?
• Do you monitor your blood sugar levels?
• History of fainting, dizziness, or LOC?
• If so, how many times in past year? 5 years?
• Look for: Glycosuria (on urine dip), Macular
degeneration, Peripheral neuropathy,
Nephropathy? TIA or stroke history?
©2014 MFMER | 3212718-43
Federal Diabetes Exemption Program
49 CFR 391.64(a)
• Group of drivers who were participants in good standing
in March 1996 were provided a letter grandfathering
them with an exemption as long as they remained
compliant with requirements
• By September 2003, the FMCSA then approved issuing
exemptions to diabetics if the driver met all guidelines
other than insulin use
• Federal Diabetes Exemption Program is responsible for
establishing driver eligibility and issues the exemption
• Exemption must be renewed every 2 years
• But every year the driver needs: ME exam, diabetologist
eval, Eye eval, education for diabetes
©2014 MFMER | 3212718-44
©2014 MFMER | 3212718-45
A 59-year-old over-the-road tractor-trailer driver
comes to your office for a DOT evaluation. He says
he had “borderline diabetes” several years prior. He
is noted to have trace glucose in his urine dip.
Further studies show a creatinine of 1.3 mg/dL,
hemoglobin A1c of 8.2%, and no peripheral
neuropathy. An eye evaluation is normal. Is taking
no oral or injectable hypoglycemic agents. What is
the next best step in assessing the driver?
©2014 MFMER | 3212718-46
What would be your next move?
1. Issue certificate and refer
to his primary provider to
initiate comprehensive
evaluation & treatment of
diabetes
2. Issue a 3-month certificate
and recheck HbA1c
3. Disqualify driver since he
cannot be certified with
diabetes
4. Refer driver to the Federal
Diabetes Exemption
Program
0%
1
0%
2
0%
3
0%
4
©2014 MFMER | 3212718-47
Blood pressure and Medical
Certification of CMV Drivers
©2014 MFMER | 3212718-48
Hypertension
• 49 CFR 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 ability
to operate a commercial vehicle.
CMV Driver Medical Examination
Measuring Blood Pressure
• Factors that may contribute to inaccurate BP
readings: e.g. too small or large of a cuff, driver
feeling anxious, just having had a tobacco
product just prior to coming for exam
• To allow for an accurate measurement of an
elevated blood pressure finding, there should
be a confirmation of this reading by at least two
subsequent measurements on the same day
• FMCSA considers two elevated BP readings at
consecutive examinations, whether follow-up or
recertification, as readings that confirm an
elevated BP
Hypertension
- Identification & History
• Hypertension is diagnosed as two readings
greater than 140/90.
• Affects over one billion individuals worldwide
and increases with age.
• History should include any OTC medications
used as well as prescription medication &
supplements including potential side effects
which may be potentially disqualifying.
• Cardiovascular co-morbidities including HTN,
congestive heart failure, myocardial infarction,
coronary insufficiency, or thrombosis
Hypertension
- Risk Identification
• When documenting medical conditions, consider rate of
progression, degree of control and likelihood of sudden
incapacitation.
• Hypertension significantly contributes to cardiovascular
morbidity and mortality by causing substantial structural
and functional adaptations, including left ventricular
diastolic dysfunction.
• Unlikely to cause a sudden collapse, however the
likelihood increases when target organ damage,
particularly if cerebral vascular disease is present.
• Hypertension and aging contribute significantly to
adverse cardiac morphology and poor outcomes.
Hypertension
- Risk Identification (cont.)
• Hypertension in the setting of target organ
damage requires further assessment to determine
functional status of the driver.
• Ideally all drivers applying for medical certification
to drive a CMV should have a serum creatinine
test with calculation of the Glomerular Filtration
Rate (GFR) in order to determine if renal disease
is present to determine the stage of the disorder.
Hypertension
- Certification Outcomes and Intervals
• Driver is required to have an exam done at least
annually.
• Disqualify a driver when evidence shows a condition
exists that will likely interfere with the safe operation of
a CMV, which, may include sufficient supporting
opinions and information from appropriate specialists.
• Document the reasons for disqualification and/or
referral.
• Advise a driver certified with a limited interval to return
for recertification with documentation for the stated
condition.
Hypertension
• All CMV drivers should be referred to their
personal provider for therapy, education, and
long-term management
• Medical Expert Panel (MEP) recommended that
the medical examiner should ensure that
individuals with hypertension are properly
educated about the importance of making
changes in lifestyle and proper compliance with
medication
Medical Examiner’s Role
• Use hypertension guidelines to determine
medical fitness for duty
• Review driver’s medications including tolerance,
effectiveness, dosage
Hypertension Standards Objectives
FMCSA recognizes three stages of hypertension:
• Stage 1: BP 140-159/90-99. Certification period
- 1 year
• Stage 2: BP 160-179/100-109. Certification
period - 3 month as a one time certificate.
Within 3 months if the BP is below 140/90 may
receive a one year certificate.
• Stage 3: BP >180/110. This is a disqualifier.
Driver may be certified if BP is less than 140/90
at 6 month intervals.
Malignant Hypertension
• Clinical presentation: patient appears ill, often
complains of a HA, blurred vision, dyspnea, and chest
pain.
• Left untreated, may result in acute renal failure, MI,
cerebral hemorrhage, severe cardiac decompensation,
or hypertensive encephalopathy.
• On physical exam: along with the severely elevated BP,
may have rales in the lung bases, marked retinal
findings are often present.
Malignant Hypertension
- Diagnostic tests and referral
• Chemistry panel
• Note any elevation in BUN and creatinine
• UA- assess for hematuria and proteinuria
• EKG
• Chest X-ray
• May need further evaluation including renal studies
• All patients with this condition need to be hospitalized
• If patient presents to clinic, call ambulance for a transfer
to ED for further evaluation
Hypertension and the Driver Medical History
- Documentation
• Confirm with driver the reason for taking an antihypertensive and advise follow up with PCP for
monitoring of medication
• Potential medication side effects of somnolence or
syncope are particularly undesirable in commercial
drivers
• Discuss lifestyle changes such as weight reduction,
increased exercise, tobacco cessation – and
document response
• Treatment includes nonpharmacologic and
pharmacologic modalities as well as counseling to
reduce other risk factors
A 46-year-old obese milk truck driver is noted to have a
bp of 130/82 in the office during his DOT medical exam.
He is on lisinopril at 10 mg daily after being noted to have
an average bp of 142/92 on initial exam.
What is the next best step?
1. Issue a 3-month
certificate and have him
return within 1 week of bp
readings
2. Issue a one-year
certificate
3. Refer him to his
cardiologist
4. Issue a two-year
certificate
0%
1
0%
2
0%
0%
3
4
©2012 MFMER | 3212718-61
Determining Certification for Hypertension
Standard Objectives
• The regulatory criteria is based on FMCSA’s
Cardiovascular Advisory Guidelines for the Examination
of CMV drivers which used the JNC-6 Report on
Detection, Evaluation, and Treatment of High Blood
Pressure.
• These requirements and guidelines developed by the
FMCSA are designed to assist the ME in making
qualification determination.
• There are many times a ME might shorten the
recommended certification process based on the
FMCSA’s Advisory Guidelines which may include the
presence of multiple co-morbidities and evidence of
target organ damage.
Laboratory Testing at Time of Exam
- Urinalysis
• Proteinuria
• Glycosuria
• Hemoglobinuria
©2014 MFMER | 3212718-63
Examiner Training:
through
Session 3
©2014 MFMER | 3212718-1
Commercial Driver Medical Examination
and Certification
Cardiovascular
Evaluation
Cardiovascular Recommendations
49 CFR 391.41(b)(4)
A person is physically qualified to
drive a commercial motor vehicle
(CMV) if that person…
• Has no current clinical diagnosis
of myocardial infarction, angina
pectoris, coronary insufficiency,
thrombosis, or any other
cardiovascular disease (CVD) of
a variety known to be
accompanied by syncope,
dyspnea, collapse, or congestive
cardiac failure.
Cardiovascular Disease
Advisory Criteria
• Definition of current generally means a diagnosis within
the last 3 months, or a diagnosis that is not stable at the
time of exam.
“Medical fitness for duty includes the ability to perform
strenuous labor. Overall requirements for commercial
drivers, as well as the specific requirements in the job
description of the driver, should be deciding factors in the
certification process.”
Advisory Criteria
• Cardiovascular insufficiency should be
evaluated, looking for:
• No physical limitations
• No residual symptoms
• No medications likely to impair abilities
• May be evident by normal resting and stress
ECG
• Implantable defibrillators are disqualifying
• Coumadin is allowed as part of medical
treatment (but need therapeutic INRs) and
novel anticoagulant agents are acceptable
- Taking a detailed history
Is there ……
• A current clinical diagnosis
of myocardial infarction,
angina pectoris, coronary
insufficiency or thrombosis
• Syncope, dyspnea, or
collapse
• Heart failure
• History of heart disease, or
acute myocardial infarction
• History of other heart conditions
• History of heart surgery,
including valve
replacement/bypass, angioplasty,
implantable cardiac defibrillator
or pacemaker
• Use of any cardiovascular
medication that effectively
controls a condition, and any side
effects from the medication that
may interfere with safe driving
- Medical Examiner responsibilities
Examination should include evaluation and
documentation of:
• Murmurs
• Arrhythmias
• Cardiomegaly
• Evidence of surgical intervention
• Evidence of congestive heart failure
• “An electrocardiogram (ECG) is required when
findings so indicate”
• Diagnostic Testing
• Electrocardiogram, Exercise stress treadmill,
LV ejection fraction, vascular studies, blood tests
(electrolytes, chemistries, toxicology) as indicated
• Chest x-ray
• Drug level monitoring when indicated (Digoxin, INR)
• Referral
• Refer a driver who exhibits evidence of a
cardiovascular disorder to another evaluating
physician (primary care or cardiologist) when
evidence of CV disorder present (e.g. MI, coronary
insufficiency, hypertension)
General guidelines for Test Results
• Exercise Stress test
• Driver should exercise to greater than
6 Metabolic Equivalents (METS)
• Attain a heart rate greater or equal to
85% of Maximum Predicted
(unless on beta blocker)
NOTE: Max predicted is 220- driver’s age
• Have a rise in systolic pressure
greater than or equal to 20mm Hg
without angina
• Have no significant ST segment
depression
General guidelines for Test Results
• Echocardiogram
• Left ventricular ejection fraction of 40% or more
• No pulmonary hypertension
• Defined as pulmonary artery pressure greater
than 50mm Hg as determined by echo or cardiac
catheterization, or
• > 50% systolic pressure, although other criteria
may be used
• ECG
• No new evidence of myocardial infarction
• If presence of arrhythmia, follow CV guidelines
Which of the following would preclude
issuing a medical certificate to a driver
after a myocardial infarction?
1. 3 months post-MI
2. Post-MI LVEF 35%
3. Taking 3 different antihypertensive
medications
4. Exercised to 7 METS
on Bruce protocol
GXT
0%
1
0%
2
0%
3
0%
4
©2014 MFMER | 3212718-11
- Post MI
Can Certify if:
• No symptoms
• 2 months or more
after MI
• LVEF ≥ 40%
• Meds well tolerated
• Cardiologist clears
One-Year Certification
Angina Pectoris
Can Certify if:
• Stable angina
• Asymptomatic
during work
activities
1-year certification
(with at least every
other year get EST)
Post Percutaneous Coronary Intervention
• Medical Expert Panel advisory currently does
not distinguish between drug-eluting stents
and bare metal stents.
- Post CABG
• Medical examiner may wish to inform specialist of pertinent
criteria needed for certification
• Some examiners create a form letter with FMCSA regulations,
and advisory criteria, asking specialist to provide documentation
that the driver is not at increased risk for syncope, dyspnea,
collapse or congestive heart failure
Drivers
without
known
CHD
…But
positive
risk
factors
Congenital Cardiovascular Disease
• See advisory criteria for
specifics, maximum allowable
1 year certification if stable
and no disqualifying features
• Annual review with
cardiologist knowledgeable of
adult congenital heart
disease
• May need annual Holter and
Echo
Heart Transplant
• May certify if at least 1 year from transplantation
• Asymptomatic
• Stable on medication
• No rejection
• Meets other criteria
• Certify every 6 months with evaluation by
cardiologist
REMEMBER -- Any disorder with an
Implantable Defibrillator
Certification NOT allowed
Mitral Valve Disease
- Mitral stenosis
Severe: MVA < 1.0 cm2
Mild to moderate:
(based on valve area*)
Certify if asymptomatic.
(One year maximum
certification)
*Mild = MVA > 1.6 cm2
*Moderate = MVA 1 to 1.6 cm2
• Post repair stand down
depends on procedure and
must be cleared by
cardiologist
(4 weeks percutaneous valvotomy, 3
months sternotomy)
One year Maximum. Annual
Cardiologist evaluation.
• If no surgery must have no
evidence failure and evidence
good exercise tolerance. See
guidelines for details.
Mitral Valve Regurgitation
Severe:
Mild and moderate:
• Ok to certify if
asymptomatic and
normal LV size and
function and normal
PA pressure
• One year maximum
• Echo annually for
moderate severity
Ok to certify if asymptomatic
& normal stress test & LV
size and function + no atrial
fibrillation, no flail leaflet,
normal PA pressures.
One year maximum, Echo
every 6 months to a year.
Post op: 3 months stand
down and then must be
cleared by cardiologist
Aortic Valve Regurgitation
Severe:
Mild to Moderate: One year
maximum certification
• Must be asymptomatic,
Normal LV function
• (note LVEF = 50%) Minimal
LV enlargement. Echo
every 2 to 3 years
• Can certify if…asymptomatic,
LV function normal (EF 50%) &
LV diameter not larger than
70mm at end diastole or 55mm
end systole
• Must have good exercise
tolerance
• Duration of certification
depends on LV diameter.
6 months with Echo: LVEDD < 60
mmHg and LVESD < 50 mmHg
4 months with Echo: LVEDD =
60 mmHg or LVESD = 50 mmHg
Aortic valve stenosis
Mild severity (AVA > 1.5 cm2)
• May certify if asymptomatic
Moderate severity (AVA
> 1.0-1.5 cm2)
• Annual recertification
• May certify for one year if
asymptomatic
• Echo every 5 years
• Recertify annually
Note: if symptoms with this
valve area you need further
evaluation with explanation
of symptoms to certify
• Echo every one to 2
years
• Post op stand down 3
months
Do not certify if severe aortic stenosis present (AVA <1.0 cm2).
Valve
replacement
Mechanical valves can be
certified if:
• 3 months post op
• asymptomatic
• cleared by a cardiologist
• seen annually by cardiologist
• one year DOT medical certification
only
Do not certify if LV dysfunction, thromboembolic
complication post procedure, pulmonary artery
hypertension, or inadequate anticoagulation.
Supraventricular Tachycardia
• Atrial fibrillation as cause of or a risk for
stroke
• Atrial fibrillation following thoracic surgery
• Atrial flutter
• Multifocal atrial tachycardia
• Atrioventricular Nodal Reentrant Tachycardia
• Atrioventricular Reentrant Tachycardia &
Wolff-Parkinson-White syndrome
Atrial arrhythmias
• Atrial fibrillation
• 1 month after adequate/stable anticoagulation
• Adequate rate control
Remember…you still
need to wait 3 months
• Cleared by cardiologist
post sternotomy if atrial
• Recertification annually
fibrillation is a post op
• Atrial flutter
• 1 month post-isthmus ablation
• Recertify annually
• Multifocal atrial tachycardia
• Ok, if asymptomatic
• No, if symptomatic
phenomenon.
Ventricular arrhythmias
Diagnosis
Physiology/
Function
Certification
Coronary Heart Disease
(CHD)
Sustained VT:
Poor prognosis and high
risk.
No
NSVT, LVEF <0.40:
Unfavorable prognosis.
No
NSVT, LVEF ≥0.40:
Generally considered to
have good prognosis.
Annual cardiology
No, if symptomatic.
Yes
examination
Inif:CHD, NSVT, with
LVEFrequired
Asymptomatic;
≥0.40:
At least 1 month after
drug
or other
therapy
Can
certify
if asymptomatic;
is successful;
At least
Cleared
by 1 month after
cardiologist.
drug or other therapy
NSVT (LVEF ≤0.40)
No
is
Dilated Cardiomyopathy
Most Ventricular tachycardias
are excluded.
successful; and cleared by
cardiologist.
No
Sustained VT, any
LVEF.
Syncope/near syncope,
any LVEF: High risk.
Hypertrophic
Cardiomyopathy
No
Variable but uncertain
prognosis.
Diagnosis
Physiology
Certification
Right Ventricular Outflow
VT
Favorable prognosis and
low risk for syncope
No, if symptomatic.
Yes, if asymptomatic.
Note certification
criterion
Idiopathic Left Ventricular
VT
Recertification
Favorable prognosis and
low risk for syncope
Yes if:
drug or other therapy
successful;
Asymptomatic;
Cleared by
electrophysiologist.
Yes if:
successful drug
therapy or ablation;
Cleared by
electrophysiologist.
High risk for ventricular
arrhythmic death
Brugada Syndrome
High risk for ventricular
arrhythmic death
Annual
Recommend evaluation
by cardiologist.
Annual
Evaluation by
cardiologist required.
No, if symptomatic
Yes, if asymptomatic.
Long QT Interval
Syndrome
Recertification
No
Do not
No certify!
Annual
Recommend evaluation
by cardiologist.
Annual
Evaluation by
cardiologist required.
Note
recertification
criteria
Pacemakers
• For sinus node
dysfunction and
atrioventricular block,
long-term prognosis is
variable depending on
the underlying disease
• Hypoperfusion (if
present) must be
corrected by support
of heart rate by
pacemaker
Pacemakers and
Syncope:
Neurocardiogenic
and Carotid Sinus
Hypersensitivity
Ok to certify if asymptomatic,
but need 3 months stand
down, AND documented
good pacemaker function
• Annual recertification required
• Must be asymptomatic
• Pacemaker checks documented
• May certify for one year
if one month after
pacemaker
implantation; need
documented correct
function and underlying
disease is not
disqualifying itself
• Recertify annually with
documented pacemaker
checks
• Excellent Long term survival
• But risk for syncope that
may be due to cardio
inhibitory or vasodepressor
components. Pacemaker
will only affect
cardioinhibitory component
though it may decrease the
impact of the vasodepressor
component.
• Bottom line: a pacemaker
may not completely resolve
the problem
Venous disease
• DVT: do not certify if
symptomatic
• For warfarin stand down
one month for regulation
and need at least monthly
INR levels with >80%
therapeutic
• Superficial Phlebitis – Ok to
certify if DVT ruled out and
no other disqualifying
diseases
(routine recertification may be
up to 2 years)
Pulmonary embolism & medical therapy
Aneurysms
©2012 MFMER | 3212718-33
Aneurysms
• Abdominal Aortic aneurysm
• Evaluate for other risk for cardiac disease
• <4.0 cm, annual recertification
• 4.0-5.0 cm if asymptomatic and cleared by a
vascular surgeon who does not recommend
surgery, annual recertification
• Do not certify if >5.0 cm, or symptomatic,
regardless of size
If driver undergoes surgery….
Must wait at least 3 months post surgery and cleared by cardiovascular
specialist before medical exam. If acceptable, then needs annual recertification.
Aneurysms
• Thoracic aneurysm:
• No certification if >3.5 cm, or symptomatic
• At least 3 months post surgery and cleared
by cardiovascular specialist, annual
certification
• May certify if < 3.5cm, asymptomatic, annual
certification
• Other arterial vessels, determine risk of rupture,
do not certify if symptomatic.
Respiratory
Disorders
Includes:
• Allergies & Asthma
• Lung carcinoma
• Chronic bronchitis/emphysema
(COPD)
• Tobacco abuse
• Emphysema
• Obstructive sleep apnea
• Infectious respiratory conditions
• Hypersensitivity pneumonitis
©2012 MFMER | 3212718-36
• Respiratory
diseases may
result in
dysfunction and
inability to
remain alert
• Many
medications
used to treat
respiratory
conditions have
untoward side
effects
©2014 MFMER | 3212718-37
Respiratory Issues
Targeted History
Physical Exam Findings
• Dyspnea?
• Normal chest wall expansion?
• Bronchitic episodes?
• Respiratory rate?
• Pneumonias?
• Cyanosis?
• Snoring or apneas?
• Clubbing? Nicotine stains?
• Daytime sleepiness?
• Normal breath sounds?
• Smoker? How long and
quantity?
• Significant kyphosis?
• Cough?
• Supplemental O2?
• Pleural friction rub?
• Use of accessory muscle of
inspiration?
• Wheezing?
©2014 MFMER | 3212718-38
Respiratory Conditions
Allergy-related
• Sinus – drivers cannot use
sedating anti-histamines
• Anaphylaxis – stinging
insect allergy, should have
Epi on board
Pulmonary HTN
• Significant if PA pressure is
>50% systolic bp
Pneumothorax
Asthma
• Must be clinically controlled
COPD
Pneumonia
TB or atypical infections
Cystic fibrosis
ILD
©2014 MFMER | 3212718-39
Indication to order spirometry:
• Any specific lung disease
• Dyspnea, cough, chest tightness, wheezing
• Cigarette smoking in driver >35 years old
Pulse Ox and ABG indicated when:
FEV1 < 65% predicted or FEV1/FVC <65%
Restrictive physiology with FVC < 60%
Screening Pulse Ox:
If < 92%, then ABG
If PaO2 <65mmHg at <5,000ft or
<60 mmHg if > 5,000 ft
Or pCO2 > 45 mmHg – do not certify
©2014 MFMER | 3212718-40
A driver with snoring, an elevated BMI
and mild HTN should also be referred
for….
1.
2.
3.
4.
5.
ABG
UPPP procedure
Polysomnography
Bronchoscopy
ECG with rhythm
strip
0%
1
0%
2
0%
0%
3
4
0%
5
©2012 MFMER | 3212718-41
Sleep apnea has been on the “radar screen” for a
long time
DOT/Federal Highway Administration's Conference on
Pulmonary/Respiratory Disorders and Commercial Drivers (1991):
• “Individuals with suspected or untreated sleep apnea
(symptoms of snoring and hypersomnolence) should be
considered medically unqualified to operate a
commercial vehicle until the diagnosis has been
dispelled or the condition has been treated successfully.
• In addition, as a condition of continuing qualification,
commercial drivers who are being treated for sleep
apnea should agree to continue uninterrupted therapy
as long as they maintain their commercial driver’s
license. They should also undergo yearly multiple sleep
latency testing (MSLT).”
©2014 MFMER | 3212718-42
50/50 rule- Half of OSAS patients have
hypertension, half of hypertensive
patients have OSAS
BMI > 125% of IBW
Neck size > 17 in
©2012 MFMER | 3212718-43
Mallampati Score
Variable reliability in predicting apnea except at the extremes,
but useful to document that you did the exam
• View pharynx with
mouth open at rest
• No phonation or
protrusion of Tongue
Grade 1: Entire tonsil
clearly visible
Grade 2: Upper half of
tonsil fossa visible
Grade 3: Soft and Hard
Palate clearly visible
Grade 4: Only Hard
Palate visible
Definitions of Sleep Disordered Breathing
Events
Apnea
Thermal sensor amplitude drops ≥ 90% of baseline for at least
10 seconds
Hypopnea
Nasal pressure amplitude drops ≥ 30% of baseline for at least
10 seconds with ≥ 4% desaturation from pre-event baseline
RERA- Respiratory Effort Related Arousal
Increasing respiratory effort OR flattening of nasal pressure
waveform for at least 10 seconds associated with arousal
Criteria for apnea or hypopnea not fulfilled
- AASM 2007
OSA Severity
• Frequency of apneas and hypopneas
-Mild : 5-15 events per hour
-Moderate: > 15-30 events per hour
-Severe: > 30 events per hour
• Additional Measures
-Degree of nocturnal hypoxemia
-Extent of sleep fragmentation (e.g., arousal index)
CPAP
47
Wear CPAP or Die?
Risks of Untreated OSAS
Apnea Index vs.
Mortality
• Probability of cumulative
survival in 142 patients
with AI< 20 (blue) vs. 104
patients (red) with AI> 20.
He J. Chest 1988: 94:9
CPAP compliance
• General
• Widely variable rates of 50-70% overall
• Probably need >4 hrs. nightly for response
• Pattern 1: 6.2 hrs./night 90% of nights (50%
pts)
• Pattern 2: 3.5 hrs./night 2-79% of nights
• Compliance determined early on
Kribbs NB. Am Rev Respir Dis 1993; 147:887-895
Weaver TE. Sleep 1997;20(4):278-83
Treatment
Oral Appliances
Mandibular devices
KlearwayGreat Lakes
Orthodontics
Tongue device
SilencerJohns Dental Labs
Tongue retaining deviceProfessional positioners
Treatment
Surgery
• Laser-assisted uvulopalatoplasty (LAUP)
• Uvulopalatopharyngoplasty (UPPP)
• Somnoplasty or Radiofrequency volumetric tissue reduction
(RFVTR)
• Maxillofacial surgery
Maintenance of Wakefulness Test (MWT)
• Four sessions, 40 minutes each, at 2 hour intervalsWalk-in or previous night PSG
• Seated quietly on bed, dark room. Subject told to
remain awake
• Nap terminated if any scorable sleep
• Though most fall asleep after much longer latency, 89% will fall asleep in < mean of 11 - 13 min
• Usual cutoff 19 min
• Most helpful outcome = no sleep
Other respiratory conditions
• Cystic fibrosis
• Document any recent exacerbations of infection or
functional limitation
• Chest wall deformities
• Significant kyphoscoliosis or pectus excavatum with
function limitation may require further evaluation
• Pneumothorax
• Should have recent chest x-ray to document
resolution
©2014 MFMER | 3212718-54
©2012 MFMER | 3212718-55
Musculoskeletal conditions
• An extremely broad category of conditions,
many with discretion of the medical examiner to
decide the interval of examination
• Any condition with poor coordination, transient
muscle weakness, or poor muscle tone may be
disqualifying if it interferes with the ability to
control and operate a CMV
• Consider the natural history and severity of the
condition, any functional limitation, whether or
not there is a risk for sudden incapacitation, or
for progressive symptoms
©2014 MFMER | 3212718-56
Fixed Extremity Deficits
Require a Skill Performance Evaluation
(SPE)
49 CFR 391.49
Need:
• Long form of ME exam
• Medical certificate copy (check
“SPE box”)
• Medical evaluation summary by
board-certified PMR or Orthopedic
specialist
• List of essential job functions from
motor carrier
• Statement from provider re:
precision prehension or power
grasp prehension
©2012 MFMER | 3212718-57
©2014 MFMER | 3212718-58
Measuring grip strength
• May use a dynamometer
• Alternatively, use an office bp
cuff bulb, having driver
squeeze bulb repeatedly
©2014 MFMER | 3212718-59
Neurological Conditions 49 CFR 391.41(b)(7)(8)(9)
• Seizure/Epilepsy
• Severe headache
• Vertigo / Dizziness
• Head trauma or loss of consciousness
• Neuromuscular conditions
©2012 MFMER | 3212718-60
Seizure history
Does driver have:
• Childhood febrile seizures?
• Provoked seizures? (e.g.
hypoglycemia, meds,
anesthesia, fever)
• Unprovoked seizure?
• Single episode?
• 2 or more seizures (which
defines epilepsy)?
• Most seizures recur within 24 months of an initial trauma or focal insult
• In stroke, 1 in 10 will have a seizure initially and up to 15% will within 5 years
• Length of time seizure free and off all anti-seizure medication is most predictive of
probability of future seizures
NOTE: Drivers must be off meds and seizure-free for 5 years for a
single unprovoked seizure, and seizure-free for 10 years and off drug
for those with epilepsy.
©2014 MFMER | 3212718-61
Headaches
• Is a common condition, but rare that a
headache would be disqualifying
• Important headache history includes: frequency,
severity, anatomic location (e.g. parietal),
association with nausea, emesis, visual
disturbance, syncope, or cognitive or motor
deficits
• Association with functionally-limiting sequelae
or medications required to treat that result in
side effects are considered disqualifying
©2014 MFMER | 3212718-62
Neuromuscular conditions
• Must consider how the neuromuscular condition will
result in functional limitation (e.g. grasping, braking,
clutching and coordination, climbing into and out of
vehicles, reaction time)
• Refer to neurologist or PM&R specialist for information
on prognosis or diagnosis
• Consider:
• Motor neuron diseases (ALS, SMA, etc.)
• Muscular dystropy
• Neuromuscular junction abnormalities (Myasthenia gravis,
Eaton-Lambert)
• Peripheral neuropathies
• Congenital myopathies
©2014 MFMER | 3212718-63
Low back pain with radiculopathy
• Because it is a
common condition, low
back pain is not
uncommonly seen by
the medical examiner
• Review physical
examination findings
that are consistent with
lumbar radiculopathy
and be familiar with
dermatomes and motor
pathways
©2014 MFMER | 3212718-64
Dementia
• Published conference reports recommended any
dementia be disqualifying, even if the diagnosis is
seriously in the differential (not even proven)
• For individuals with very early symptoms or slow
rate of progression, disqualification was deemed
“mandatory” by the MEP
• All individuals with dementia-like symptoms need
imaging of the brain and neuropsychiatric/cognitive
testing
©2014 MFMER | 3212718-65
Stroke
• Prevalent issue affecting > 3
million in the US each year
For embolic stroke, TBI
or bleeds, will need to
consider neurocognitive
• Refer to a neurologist if not
testing within 90 days of
already seen
DOT exam if there are
• Cortical and subcortical lesions
are associated with increased any questions of
memory loss or
seizure risk
executive function.
• Brainstem and cerebellar
infarcts not associated with
seizure risk
• Disqualified for one year and
require annual certification
• TIA requires 1 year
stand down and
neurology evaluation
©2014 MFMER | 3212718-66
This driver took a jump at
full speed while
impressing his girlfriend
while snow boarding. Had
loss of consciousness for
60 minutes after the injury.
After surgical evacuation
of the hematoma, he has
remained seizure-free. He
comes to you four months
later and requests a DOT
medical exam in hopes of
working as a delivery truck
driver.
Do you certify this driver?
©2014 MFMER | 3212718-67
Certify?
1. Yes
2. No
0%
1
0%
2
©2012 MFMER | 3212718-68
Goals of Medication and Substance Use
Review
• Identify illicit drug use
• Identify alcoholism
• Identify legal or prescribed drugs/substances which
may impair driving or related medical condition which
would lead to exclusion or other DOT consequence
• Exclude drivers with alcoholism, substance abuse and
use of prohibited/impairing prescription drugs until they
meet criteria for recertification
• Counsel drivers on risks of over-the-counter
substances
©2014 MFMER | 3212718-69
49 CFR 391.41(b)(12)
The Federal Motor Safety Regulations that address substance abuse
and alcohol misuse [49 DFR 391.41(b)] state that a person is
physically qualified to drive a commercial motor vehicle (CMV) if that
person
(12)(i) Does not use a controlled substance identified in 21
CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other
habit-forming drug.
(ii) Exception. A driver may use such a substance or drug, if
the substance or drug is prescribed by a licensed medical practitioner
who:
Is familiar with the drivers medical history and assigned duties; and
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; and
(13)Has no current diagnosis of alcoholism.
©2014 MFMER | 3212718-70
Targeted history directed at driver
• Ask: current use, recent drug treatment, legal issues
pending.
• Ask: ever used, ever in drug or alcohol treatment, ever
had DUI or other legal issues related to chemicals.
• See: if the individual is currently under the influence
behavior may be erratic, pupils dilated or pinpoint
depending on drug of choice (more likely they will not
come currently using).
• See (not an exhaustive list):
• Methamphetamine: skin lesions poor dentition
• Injection drugs: needle tracks
• Cocaine nasal findings
©2014 MFMER | 3212718-71
“Meth” Mouth and “meth” mites
©2014 MFMER | 3212718-72
Lets be real…..and really careful
• You should ask
• You should look
• But obvious findings aside, what else can you do?
• Is your driver accident prone?
(falls, fractures etc?)
• An early MI without risk factors?
If you are concerned you may do what ever testing
you feel you need to sort out the issue.
©2014 MFMER | 3212718-73
Current diagnosis of alcoholism
• For purposes of deciding on a “current”
diagnosis of alcoholism, active participation in
AA or other self help is not a reason to
disqualify
• Should be sober and have completed treatment
and be medically stable from the consequences
of alcoholism
• If you have a question about fitness to drive,
refer to a Substance Abuse Professional
©2014 MFMER | 3212718-74
Alcoholism
• Use a screening test of choice
• CAGE
• TWEAK
• Audit
Can be done as screening form in your
practice on all drivers
©2014 MFMER | 3212718-75
If you identify active substance or
alcohol abuse
• Disqualify
• Refer to a substance abuse professional SAP
• Return to driving will require successful
treatment and negative drug testing
• The examiner may certify the driver for less
than 2 years if there is concern for relapse
©2014 MFMER | 3212718-76
Prescription medications that are narcotic,
amphetamine, or habit forming
• State of the science is lacking
• The state of policy/statute is lacking
• Disqualify unless there is a written document
from the prescriber stating that the
substance will not affect the drivers ability to
safely operate a commercial motor vehicle
©2014 MFMER | 3212718-77
What do we know
• Stimulants may not have an effect on driving safety
• Opioids have a deleterious effect initially (consider a
delay of driving with a new prescription and avoid
intermittent use)
• Barbiturates do not have enough evidence to establish
a safety risk
• Provigil (see FAQ’s in Tool Kit and FMCSA web site)
• Drivers using this drug should not be qualified until
they have been monitored closely for at least 6
weeks. The treating provider and the medical
examiner should agree that the Provigil is effective
in preventing daytime somnolence, and that there
are no side effects.
©2014 MFMER | 3212718-78
Expert Panel recommendations on
medications
• Other expert panels have given
recommendations regarding the use of
psychoactive medications including
benzodiazepines and antipsychotics
• Certain antihypertensives
• More than 500 prescription drugs have a
sedation warning
• Sleep driving is a real issue for certain legal
prescription drugs
©2014 MFMER | 3212718-79
Absolutes
• Methadone is an absolute disqualification
• Medical marijuana is an absolute disqualification
©2014 MFMER | 3212718-80
Counseling regarding use of medications
• You must counsel the driver to use medications
as prescribed
• Drivers must be careful about over-the-counter
medications which may be more impairing than
prescription drugs
• Of specific concern -- sedating antihistamines
• Use of a single dose of sedating antihistamine has
been shown to be more impairing than illegal level of
alcohol
• Use of someone else’s prescription drug is unlawful
and disqualifying for unauthorized use
©2014 MFMER | 3212718-81
Benzodiazepines
• There is good evidence that benzodiazepines
are associated with an increased incidence of
road accidents.
©2014 MFMER | 3212718-82
Pramipexole and ropinirole
• Associated with sleep attacks that are
unpredictable and have occurred one year after
beginning the medication – therefore,
disqualifying at this time
©2014 MFMER | 3212718-83
Examiner Training:
through
Session 4
©2014 MFMER | 3212718-1
What
Is my role as a Medical
Examiner?
©2014 MFMER | 3212718-2
Split Roles of the Medical Examiner
Driver advocate vs. “forensic scrutinizer”
As a medical examiner the
fundamental obligation is to establish
whether the driver has a condition
resulting in a higher than acceptable
likelihood for gradual or sudden
incapacitation or sudden death, thus
endangering public safety (i.e. a
“medical fitness for duty” exam).
©2014 MFMER | 3212718-3
*from the FMCSA Medical Examiner’s Handbook
©2014 MFMER | 3212718-4
Driver advocate vs. “forensic scrutinizer”
• Any time a driver, in your opinion, poses a risk to public safety, you
should not certify the driver as medically fit for duty.
• As you conduct the physical examination to determine if the driver is
medically fit to perform the job of commercial driving, you must
consider:
Physical conditions
Mental conditions
Medical treatments (and side effects)
©2014 MFMER | 3212718-5
Physical condition
• Symptoms — Does a benign underlying condition with an excellent prognosis
have symptoms that interfere with the ability to drive (e.g., a benign
supraventricular arrhythmia that causes syncope)?
• Incapacitation — Is the onset of incapacitating symptoms so rapid that
symptoms interfere with safe driving, or can the driver stop the vehicle safely
before becoming incapacitated? Is the onset of incapacitating symptoms so
gradual that the driver is unaware of diminished capabilities, thus adversely
impacting safe driving?
Mental condition
• Cognitive — Can the driver process environmental cues rapidly and make
appropriate responses, independently solve problems, and function in a
dynamic environment?
• Behavior — Are the driver interactions appropriate, responsible, and
nonviolent?
Medical treatment (and side effects)
• Effects — Does treatment allow the driver to perform tasks safer than without
treatment?
• Side effects — Do side effects interfere with safe driving (e.g., drowsiness,
dizziness, orthostatic hypotension, blurred vision, and changes in mental
status)?
©2014 MFMER | 3212718-6
Driver advocate vs. Forensic scrutinizer
• As the medical examiner, you are examining for medical fitness for duty, not
diagnosing and treating personal medical conditions.
Drivers must:
• Comply with FMCSA regulations.
• Seek further testing/evaluations for those medical conditions of which you are
unsure.
• Refer the driver to his/her personal health-care provider for diagnosis and
treatment of potential medical conditions discovered during your examination.
• Promote public safety by educating the driver about:
• Side effects caused by the use of prescription and/or over-the-counter
medications.
• Medication warning labels and how to read them.
• The importance of seeking appropriate intervention for non-disqualifying
conditions, especially those that, if neglected, could result in serious illness
and possible future disqualification.
©2014 MFMER | 3212718-7
Protected Health Information (PHI)
• Although regulatory requirements trump rules under HIPPA (Health
Insurance Portability & Accountability Act of 1996), specific
inquiries regarding what can be turned over to the employer should
be directed toward appropriate legal counsel
• Although the Federal Motor Carrier Safety regulations do not
require the medical examiner to give a copy of the Medical
Examination Report form to the employer, the FMCSA does not
prohibit employers from obtaining copies of the Medical
Examination Report form.
• Medical examiners should have a release form signed by the driver
if the employer wishes to obtain a copy of the Medical Examination
Report form.
• Employers must comply with applicable State and Federal laws
regarding the privacy and maintenance of employee medical
information.
©2014 MFMER | 3212718-8
Cases
©2012 MFMER | 3212718-9
58-year-old male with
interstitial lung disease
requests to drive a school
bus part-time.
• FEV1 is 0.95 L (30% predicted)
• On 4L/min supplemental O2 via NC with measured
SpO2 of 96%
• On lung transplant list
• Job description reads, “Walk up 3 steps. Sit 45
minutes. Walk down 3 steps.”
Would you certify this man?
©2014 MFMER | 3212718-10
As the medical examiner (ME), I would…
1.
2.
3.
4.
Certify for 2 years
Certify for 1 year
Certify for 6 months
Certify for 3 months
and request more
medical records
5. Do not certify
0%
1
0%
2
0%
0%
3
4
0%
5
©2014 MFMER | 3212718-11
67-year-old man has indicated that
he experiences intermittent chest
pain that is worse with exertion
and relieved with rest. It is
substernal and occasionally
radiates to his left arm. A 12-lead
ECG is unremarkable.
©2014 MFMER | 3212718-12
After placing the exam in abeyance (or
temporarily disqualifying), what testing
would you do next?
1.
2.
3.
4.
Lung scan (V/Q)
Echocardiogram
Exercise stress test
Coronary
angiogram
5. EGD
0%
1
0%
2
0%
0%
3
4
0%
5
©2014 MFMER | 3212718-13
Auditory Testing Results
Screening Test
• Whispered voice test is 3 feet in
the worst ear
• Whispered voice test is 4 feet in
the best ear
©2014 MFMER | 3212718-14
Would you certify this driver?
1. No, disqualify.
2. Yes, meets
standards.
3. No, but need to do
audiometry
0%
1
0%
2
0%
3
©2014 MFMER | 3212718-15
Audiogram
Left Ear
Right Ear
500 Hz
20 dB
500 Hz
30 dB
1000 Hz
60 dB
1000 Hz
40 dB
2000 Hz
70 dB
2000 Hz
50 dB
©2014 MFMER | 3212718-16
Would you certify based upon audiometry
results?
1. Yes
2. No
3. Defer exam to
State DOT for
further input.
0%
1
0%
0%
2
3
©2014 MFMER | 3212718-17
52 year old female quit her job as a
medical secretary because it was not
exciting enough, and decided to become
an OTR truck driver.
Examination reveals bilateral numbness and
tingling of her hands.
What are some things you might consider based
upon examination?
©2014 MFMER | 3212718-18
60-year-old male regional hauler moving
new automobiles was treated for a
myocardial infarction 3 months ago. He is
asymptomatic and had completed cardiac
rehabilitation. His blood pressure is normal,
he remains asymptomatic, and has no
musculoskeletal issues.
©2014 MFMER | 3212718-19
Which of the following findings would
prevent him from being certified right now?
1. LVEF of 35% on echo
2. Only 3 months out
from MI
3. Brief runs of
ventricular tachycardia
at the time he
received thrombolytics
4. Exercise for 9 minutes
on a full Bruce
protocol treadmill
0%
1
0%
2
0%
3
0%
4
©2014 MFMER | 3212718-20
46 year-old obese male falls asleep in your
waiting room filling out his insurance forms.
He explains that he has always been a
person who takes a “cat nap” in the
afternoon.
Exam shows an obese male with a BMI of
48 kg/m3. Mallampati IV/IV posterior
oropharynx identified. Large, protuberant
abdomen is noted. When asked, neck size
is 18 1/2 in.
©2014 MFMER | 3212718-21
After completing the exam and reviewing
his history, what do you do next?
1. Refer for stress
echocardiogram
2. Order overnight pulse
oximetry
3. Consult cardiology
4. Check fasting glucose.
0%
1
0%
2
0%
3
0%
4
©2014 MFMER | 3212718-22
You see a driver you have known for 20
years who has been documented to have
mild essential HTN and who has been on
lisinopril at 10 mg daily for the past 10
years. There have been no changes in his
health and his exam is unremarkable. His
blood pressure in the office is 136/78. You
go ahead and issue the driver a certificate
valid for 2 years.
©2014 MFMER | 3212718-23
Is issuing this medical certificate for 2
full years legal?
1. Yes
2. No
0%
1
0%
2
©2014 MFMER | 3212718-24
You see a 67-year-old male driver for a
CMV medical. He states he has no medical
issues. However, on exam you note he has
a glass eye. Exam is otherwise normal.
What should you do?
1. Deny the certificate.
2. Certify for 3 months.
3. Certify with need for
vision exemption.
4. Defer medical
application to the
FMCSA.
©2014 MFMER | 3212718-25
Examiner Training:
through
Session 5
©2014 MFMER | 3212718-1
Registering
For the
Exam
©2014 MFMER | 3212718-2
What you need to do
• Register on the NRCME to get your
examiner number
• Sign up and select date for the exam on
line
• Find convenient testing center and pay
fee
• Have available a copy of medical
license, proof of course completion,
approved governmental ID
©2014 MFMER | 3212718-3
©2012 MFMER | 3212718-4
©2012 MFMER | 3212718-5
©2012 MFMER | 3212718-6
©2012 MFMER | 3212718-7
©2012 MFMER | 3212718-8
©2012 MFMER | 3212718-9
©2012 MFMER | 3212718-10
©2012 MFMER | 3212718-11
©2012 MFMER | 3212718-12
©2014 MFMER | 3212718-13
©2012 MFMER | 3212718-14
©2012 MFMER | 3212718-15
©2012 MFMER | 3212718-16
©2012 MFMER | 3212718-17
©2012 MFMER | 3212718-18
©2014 MFMER | 3212718-19
©2014 MFMER | 3212718-20
©2012 MFMER | 3212718-21
What you will be required to do once validated
• Once every calendar month, each medical examiner listed on the
National Registry is required to complete and transmit to FMCSA a
Form MCSA-5850, CMV Driver Medical Examination Results, with
the following information about each CMV driver examined during
the previous month:
•
An indication of the examination outcome (for
example, medically qualified)
•
Whether the driver is an intrastate driver only
• Driver’s license number and State
•
Whether the driver is a CDL holder
• Date of examination
•
Date of driver medical certification expiration
•
Any restrictions and variances (for example,
wearing corrective lenses or driving within an
exempt intra-city zone)
• Name
• Date of birth
©2014 MFMER | 3212718-22
©2012 MFMER | 3212718-23
What you will be required to do once validated
(cont.)
You must submit this data electronically via a
secure FMCSA-designated website. In order to
continue to be listed on and to continue
participation in the National Registry, you need to
comply with this requirement on a monthly basis.
If you have not conducted any exams during the
month, that must be reported as well.
You will be required to take training every 5 years and
an exam every 10 years.
©2014 MFMER | 3212718-24
Performance monitoring
• Medical examiners must provide Medical Examination
Reports and medical examiner’s certificates to an authorized
representative, special agent, or investigator of FMCSA or an
authorized State or local enforcement agency representative
to ensure compliance with FMCSA medical standards and
guidelines in performing CMV driver medical examinations.
FMCSA monitors medical examiner performance by:
• Conducting periodic reviews of randomly selected
medical examiners listed on the National Registry
Website to ensure that CMV driver examinations are
being conducted properly.
• Periodically reviewing a representative sample of the
Medical Examination Reports associated with the name
and numerical identifiers of applicants/drivers for errors,
omissions, or other indications of improper certification.
©2014 MFMER | 3212718-25
Performance monitoring (cont.)
• To comply with performance monitoring, you must:
• Retain each original (paper or electronic) completed
Medical Examination Report and a copy or
electronic version of each medical examiner's
certificate on file for at least 3 years from the date of
the of examination.
• Make all records and information in these files
available to an authorized representative of FMCSA
or an authorized Federal, State, or local
enforcement agency representative, within 48 hours
after the request is made for investigations and
within 10 days of requests for regular audits.
©2014 MFMER | 3212718-26
Thanks for your
participation!
©2012 MFMER | 3212718-27
1
Toolbox Links
FMCSA Tools
**Medical Examiner Handbook
http://nrcme.fmcsa.dot.gov/mehandbook/MEhandbook.aspx
National Registry of Certified Medical Examiners
http://nrcme.fmcsa.dot.gov/
Office of Medical Programs
http://www.fmcsa.dot.gov/regulations/medical Medical Advisory Criteria Under Evaluation
http://www.fmcsa.dot.gov/regulations/rulemaking
Medical Review Board
http://www.mrb.fmcsa.dot.gov/ Federal Advisory Committee Act
http://www.gsa.gov/portal/content/100916
Frequently Asked Questions (FMCSA)
http://www.fmcsa.dot.gov/rules-regulations/topics/medical/faqs.aspx
Frequently Asked Questions (NRCME)
http://nrcme.fmcsa.dot.gov/documents%5CNational_Registry_FAQ.pdf
Definitions
Administrative Definitions
http://www.fmcsa.dot.gov/rulesregulations/administration/fmcsr/fmcsrruletext.aspx?reg=383.5
Forms
Form 649-F
http://www.fmcsa.dot.gov/documents/forms/649f.pdf
Medical Certificate
http://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Medical_Examiners_Certificate.pdf
Skill Performance Evaluation for Limb Injury or Limitation
http://www.fmcsa.dot.gov/rules-regulations/topics/medical/spepackage.htm
Drug & Alcohol Testing
http://www.dot.gov/business/drug-and-alcohol-testing/dot-rule-49-cfr-part-40-section-403
Vehicle Crash Statistics
Vehicle Crash Statistics
http://www-nrd.nhtsa.dot.gov/Pubs/811552.pdf
Office of Analysis, Research & Technology
http://www.fmcsa.dot.gov/safety/analysis-research-technology
Other Department of Transportation Guides
FAA Aviation Medical Examiner Guidelines
http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/
Federal Transit Administration (Prescription and OTC Medication Guides)
http://www.fta.dot.gov/documents/RxOTC_April2011.pdf
Occupational Safety & Health Administration
OSHA Guide for Trucking Industry
http://www.osha.gov/SLTC/trucking_industry/index.html
Trucking Industry
Health of Truck Drivers on the Road
http://www.truckertrucker.com/article/1952
American Trucking Associations
http://www.trucking.org/
Trucking Industry Defense Association
http://www.tida.org/
Owner-Operator Independent Drivers Association
http://www.ooida.com/
American Association of Owner Operators
http://www.aaofoo.com/
Complete Guide to
Medical Examiner Certification
March 25, 2013
Complete Guide to Medical Examiner Certification
Table of Contents
Introduction .................................................................................................................................................. 5
The National Registry Overview.................................................................................................................... 5
National Registry Background................................................................................................................... 5
Objectives.............................................................................................................................................. 5
This Guide ............................................................................................................................................. 5
The Certification Test.................................................................................................................................... 5
Test Construction ...................................................................................................................................... 6
Test Content.............................................................................................................................................. 6
Test Specifications ................................................................................................................................ 6
Eligibility Requirements ................................................................................................................................ 7
Training ..................................................................................................................................................... 7
Test Application ............................................................................................................................................ 8
Testing Organizations................................................................................................................................ 8
Application Procedures............................................................................................................................. 9
Registration........................................................................................................................................... 9
Taking the FMCSA Medical Examiner Certification Test............................................................................... 9
Scheduling the Test................................................................................................................................... 9
Test Fees ................................................................................................................................................. 10
Test Preparation...................................................................................................................................... 10
Test Taking Tip ........................................................................................................................................ 10
Sample Certification Test Items .............................................................................................................. 10
Resources .................................................................................................................................................... 10
National Registry Website and Listserv .................................................................................................. 10
Resources on the National Registry Website.......................................................................................... 11
Sample Training .................................................................................................................................. 11
Medical Examiner Handbook.............................................................................................................. 11
Information Manual for Training Organizations ................................................................................. 11
Administrative Manual for Testing Organizations .............................................................................. 11
Testing Policies and Procedures ................................................................................................................. 11
The Day of the Test ................................................................................................................................. 11
Security ............................................................................................................................................... 12
Page 2 of 44
At a test center.................................................................................................................................... 12
Online testing...................................................................................................................................... 12
During testing the following apply:..................................................................................................... 12
Timed Test........................................................................................................................................... 13
Misconduct ......................................................................................................................................... 13
Test Procedures ...................................................................................................................................... 13
Candidate Comments and Feedback .................................................................................................. 13
Receiving Test Score/Passing the Test................................................................................................ 13
Not Passing the Test............................................................................................................................ 14
Confidentiality..................................................................................................................................... 14
Quick Reference Guide ....................................................................................................................... 14
Maintaining Certification ............................................................................................................................ 14
Listing on the National Registry .............................................................................................................. 15
Driver Examination Reports .................................................................................................................... 15
Performance Monitoring ........................................................................................................................ 15
Auditing................................................................................................................................................... 16
Removal from the National Registry........................................................................................................... 16
Reasons for Removal............................................................................................................................... 16
Procedure for Removal ........................................................................................................................... 16
Voluntary Removal.............................................................................................................................. 16
Involuntary Removal: Notice of Proposed Removal .......................................................................... 17
Response to Notice of Proposed Removal and Corrective Action.......................................................... 17
Opposing a Notice of Proposed Removal ........................................................................................... 17
Compliance and Corrective Action ..................................................................................................... 17
Request for an Administrative Review.................................................................................................... 18
Emergency Removal............................................................................................................................ 18
Reinstatement on the National Registry............................................................................................. 18
Effect of Final Decision by FMCSA ...................................................................................................... 18
Appendices.................................................................................................................................................. 19
Appendix A: National Registry of Certified Medical Examiners Medical Examiner Training, Guidance
for the Core Curriculum Specifications ................................................................................................... 19
Appendix B: Detailed Content Outline................................................................................................... 26
Page 3 of 44
Appendix C: Sample FMCSA Medical Examiner Certification Test Items............................................... 35
Appendix D: Quick Reference Guide...................................................................................................... 41
Appendix E: FMCSA Form MCSA-5850, CMV Driver Medical Examination Results............................... 43
Page 4 of 44
Introduction
The National Registry of Certified Medical Examiners (hereinafter referred to as the “National Registry”)
was established in accordance with the final rule published by the Federal Motor Carrier Safety
Administration (FMCSA) in the Federal Register on April 20, 2012. This rule requires that all medical
examiners who conduct physical examinations for interstate commercial motor vehicle (CMV) drivers:
•
•
•
•
Maintain a valid State license to conduct medical examinations;
Complete required training on FMCSA’s physical qualification standards;
Pass the FMCSA Medical Examiner Certification Test to demonstrate knowledge of FMCSA’s
physical qualification standards; and
Complete refresher training every 5 years and recertification testing every 10 years.
Beginning May 21, 2014, all medical certificates issued to interstate truck and bus drivers must come from
medical examiners listed on the National Registry.
The National Registry Overview
In August 2005, Congress enacted the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A
Legacy for Users (SAFETEA-LU), which authorized FMCSA to establish the National Registry of Certified
Medical Examiners (49 U.S. Code 31149).
National Registry Background
The National Registry is designed to improve highway safety by producing trained, certified medical
examiners who can determine whether a CMV driver meets FMCSA standards and guidelines.
Objectives
The objectives of the National Registry Program are:
•
•
•
•
•
Improve highway safety;
Ensure that medical examiners understand FMCSA medical standards and guidelines and
how they apply to interstate CMV drivers;
Maintain training and testing program for medical examiners;
Promote public confidence in the quality of the medical examiners who certify CMV drivers;
and
Establish an online list of certified medical examiners.
This Guide
This Complete Guide to Medical Examiner Certification is designed to help medical examiners apply and
prepare for the FMCSA Medical Examiner Certification Test and can be used as a reference tool after
certification. The Guide provides information about eligibility requirements, applying to take the
certification test, the certification testing process, and maintaining certification. It also includes
information about FMCSA policies and procedures for listing on the National Registry.
The Certification Test
FMCSA modeled the development of the certification test on recognized processes and procedures
established by the National Commission for Certifying Agencies (NCCA), a national accreditation body for
a variety of certification programs and organizations that assess professional competency. The NCCA
uses a peer review process to establish accreditation standards, evaluate compliance with the standards,
Page 5 of 44
recognize organizations and programs that demonstrate compliance, and serve as a resource on quality
certification. FMCSA used these standards for certification test development so medical examiners, the
drivers they examine, the motor carriers that employ the drivers and the public would have confidence in
the qualifications of FMCSA certified medical examiners.
Test Construction
FMCSA performed an extensive role delineation study to identify the critical knowledge, skills, and
abilities needed to perform CMV driver physical examinations in accordance with current FMCSA
regulations and advisory criteria. A variety of methods were used to complete the study, including an
literature review, direct observations of CMV driver physical examinations, a national survey of medical
examiners, and medical examiner expert Working Integrated Product Team (WIPT) meetings. The study
results provided a blueprint for the FMCSA Medical Examiner Certification Test and the development of
core curriculum specifications for the initial medical examiner training that will be provided by privatesector training organizations.
Test Content
Test Specifications
The final test specifications shown in Table 1 reflect the number of items and cognitive level of questions
for each content area on the certification test. These specifications were developed combining medical
examiner survey results and consensus of WIPT members. This blend of survey results and consensus
among medical examiners is superior to using either element alone.
Table 1: Core Content Areas
Items
FMCSA Medical Examiner Certification Test
Content Area
I. DRIVER’S MEDICAL INFORMATION
Cognitive Level
Recall
Application
Analysis
Totals
23
33
14
70
A. Identification and History
4
6
10
20
B. Physical Examination and Evaluation
8
15
2
25
C. Diagnostic Tests and/or Referrals
6
10
2
18
D. Documentation of Ancillary Information
5
2
0
7
7
12
11
30
A. Health Education Counseling
2
1
1
4
B. Risk Assessment
2
4
8
14
C. Certification Outcomes and Intervals
3
7
2
12
30
45
25
100
II. DETERMINATION OF DRIVER’S QUALIFICATIONS
AND DISPOSITION
Totals
Page 6 of 44
Eligibility Requirements
To be eligible to take the FMCSA Medical Examiner Certification Test, the medical examiner candidate
must:
•
Meet the professional requirements established in 49 CFR 390.103(a) (1): Medical Examiner
must “be licensed, certified, or registered in accordance with applicable State laws and
regulations to perform physical examinations. The applicant must be an advanced practice nurse,
doctor of chiropractic, doctor of medicine, doctor of osteopathy, physician assistant, or other
medical professional authorized by applicable State laws and regulations to perform physical
examinations.”
•
Complete required initial medical examiner training on the FMCSA physical qualification standards, guidance and related knowledge for CMV drivers.
Training
Initial medical examiner training must be completed prior to sitting for the FMCSA Medical Examiner
Certification Test. The training reviews FMCSA-specific knowledge about CMV drivers and the physical
and mental demands of their job. This training is required because specialized knowledge of CMV drivers
is not included in healthcare practitioner education and licensure.
Medical examiner training ensures that candidates have baseline instruction in FMCSA’s CMV driver
physical qualification standards, medical guidelines, and medical examiner responsibilities. Medical
scope of practice is defined by each State. It demonstrates the practitioner’s clinical knowledge. The
medical examiner training builds on that clinical knowledge and applies it to the fitness for duty
determination for CMV drivers.
FMCSA provides a list of required training topics to private-sector professional associations, health care
organizations, and other for-profit and non-profit training providers. A detailed list of training topics can be
found in the National Registry of Certified Medical Examiners Medical Examiner Training, Guidance for
the Core Curriculum Specifications in Appendix A. Training providers choose the training delivery
method, which may include but is not limited to the following: traditional instructor-led classroom
instruction; self-paced, computer- or web-based learning; a combination of both; or a guided literature
review.
There is no FMCSA requirement for length of training. Training providers are not reimbursed by the
Federal government for developing training courses and may charge reasonable fees to those candidates
who choose to attend. The training program must meet the following requirements:
•
•
•
Be conducted by a training provider that is accredited by a nationally-recognized medical
profession accrediting organization to provide continuing education units;
Present course content that addresses the eight topics outlined in the current core curriculum
specifications established by FMCSA.
Provide the medical examiner with proof of training. FMCSA recommends providing medical
examiner with a certificate of completion. The training certificate must include the following
information:
o Medical examiner’s name and professional title.
o Date training was completed.
o Training provider name and contact information.
o Title of training program.
o Training program accreditation information, including:
- Name of accrediting body.
- Affirmation of accreditation in accordance with the requirements of the accrediting
body.
Page 7 of 44
-
Accrediting body contact information.
NOTE: The medical examiner can attend a training program accredited by any medical profession
accrediting organization (i.e. a physician can complete a training program accredited by a nurse
practitioner accrediting organization).
Test Application
Testing Organizations
The FMCSA Medical Examiner Certification Test is delivered only by testing organizations that have been
approved by FMCSA and listed on the National Registry Website (https://nationalregistry.fmcsa.dot.gov).
Approved testing organizations administer only the currently authorized version of the certification test
developed and furnished by FMCSA. To accommodate the number of potential medical examiners and
their geographic dispersion, the FMCSA Medical Examiner Certification Test is administered by multiple,
private-sector, professional testing organizations. In addition, the Agency is permitting testing
organizations to offer online monitored testing. Given the variety of testing organizations and methods
used, it is important to maintain common standards of test presentation, facilities, data security, and other
factors. These standards must be carefully defined and applied so medical examiners have an equal
opportunity to demonstrate their knowledge without concern for the reliability or validity of the test and its
administration. 49 CFR 390.107 establishes these standards, and states (in part):
(a) The testing organization has documented policies and procedures that:
1. Use secure protocols to access, process, store, and transmit all test items, test forms,
test data, and candidate information and ensure access by authorized personnel only.
2. Ensure testing environments are reasonably comfortable and have minimal
distractions.
3. Prevent to the greatest extent practicable the opportunity for a test taker to attain a passing score by fraudulent means.
4. Ensure that test center staff that interact with and proctor examinees or provide technical support have completed formal training, demonstrate competency, and are monitored periodically for quality assurance in testing procedures.
5. Accommodate testing of individuals with disabilities or impairments to minimize the effect of the disabilities or impairments while maintaining the security of the test and data.
(b) Testing organizations that offer testing of examinees at locations that are not operated and staffed by the organization by means of remote, computer-based systems, must, in addition to the requirements of paragraph (a), ensure that such systems:
1. Provide a means to authenticate the identity of the person taking the test.
2. Provide a means for the testing organization to monitor the activity of the person taking
the test
3. Do not allow the person taking the test to reproduce or record the contents of the test by
any means.
(c) The testing organization has submitted its documented policies and procedures as defined in paragraph (a) of this section to FMCSA; and agreed to future reviews by FMCSA to ensure compliance with the criteria listed in this section.
The testing organization administers only the currently authorized version of the FMCSA Medical
Examiner Certification Test developed and furnished by FMCSA.
Page 8 of 44
Application Procedures
Registration
Step 1: Create Your Account
•
•
•
•
Create your National Registry Account at https://nationalregistry.fmcsa.dot.gov.
Select “Registration” option.
Enter requisite information. (You must complete registration or your data will not be saved).
Verify all information and submit.
Step 2: Accept Rules of Behavior
The following medical examiner Rules of Behavior will be displayed and must be affirmed and submitted
before registration is complete:
•
•
•
•
•
Statement of capability and willingness to comply with the FMCSA requirement to transmit CMV
driver examination data to FMCSA electronically once every calendar month.
Statement agreeing to provide copies of certification of training completion, State license(s),
certificate(s), or registration(s) to perform physical examinations, completed Medical Examination
Reports, and medical examiner certificates to an authorized representative of FMCSA or to an
authorized State or local enforcement agency representative upon request.
Statement agreeing to accept any written communication from FMCSA relating to participation on
the National Registry by electronic mail at the email address(es) provided to FMCSA, including
any notice of proposed removal from the National Registry and any such information addressing
obligations as a certified medical examiner.
Statement that all information submitted to FMCSA is true, and accepts the terms.
Statement agreeing to the National Registry/FMCSA Privacy Policy.
Once registration is complete, you will receive a welcome message and a National Registry Number. You
will then receive an email with a temporary password and instructions for next steps.
Taking the FMCSA Medical Examiner Certification Test
Scheduling the Test
•
•
•
Go to https://nationalregistry.fmcsa.dot.gov to find links to testing organizations approved to
administer the FMCSA Medical Examiner Certification Test.
Obtain information about locations and scheduling instructions directly from the testing organizations.
Schedule a date and time to take the test. Some testing organizations may provide an option to
take the test using a secure, remote, computer-based system. If you choose that option, you will
need to follow their procedures for making those arrangements.
IMPORTANT: It is your responsibility to keep your contact and licensing information up to date on the
National Registry. If your license has expired or your name changes, you MUST put the correct
information into the National Registry. Be sure to update the contact (e.g. name, address, etc.) and
medical licensing information (e.g. license expires, license number, license state, etc.) you entered when
registering on the National Registry website when there are changes. If the contact and medical licensing
information you entered during registration on the National Registry website does not match the
credentials you present to the test center, you will not be allowed to take the exam.
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Test Fees
Although FMCSA reviews the policies and procedures submitted by testing organizations before
approving them to provide the test, it does not establish, or regulate the fees established and collected by
testing organizations, and does not receive any monies collected by testing organizations or providers.
Testing providers are not reimbursed by the Federal government and may charge fees they deem
appropriate for test delivery. The testing provider is responsible for the entire process of fee
determination, collection, and refund, if warranted, as well as the advertising of the testing service,
determining the testing schedule, and managing applications submitted by candidates taking the
certification test.
Test Preparation
As a candidate for the FMCSA Medical Examiner Certification Test, you should review the complete
Detailed Content Outline (DCO) in Appendix B to understand the scope and complexity of the test. Test
items are limited to the critical tasks specified in the DCO, which identifies the following:
•
•
•
•
Task
Cognitive level required to respond to each item
Number of items by major content domain
Number of items by cognitive level
Test Taking Tip
CMV driver medical certification is based on comprehensive physical assessment of driver health. This
includes the medical examiner’s informed judgment about the potential impact of a single medical
condition or multiple existing medical conditions on the driver’s ability to operate a CMV safely in
interstate commerce.
Sample Certification Test Items
Sample test items provide an idea of what to expect on the certification test. Appendix C of this Guide
provides several sample test items.
Resources
National Registry Website and Listserv
FMCSA developed the National Registry Website and the National Registry Listserv to disseminate
information including the latest National Registry developments and to facilitate communication with the
program’s primary stakeholders: medical professionals interested in becoming certified medical
examiners; certified medical examiners; industry professionals; CMV drivers; employers; the general
public; and all other interested parties.
The National Registry Website (https://nationalregistry.fmcsa.dot.gov) provides information about FMCSA
regulations and other requirements relevant to CMV driver physical examinations. The website will
include a continually updated list of certified medical examiners that are authorized by FMCSA to perform
physical examinations for interstate CMV drivers.
Medical professionals interested in becoming certified medical examiners and being listed on the National
Registry can find information about the medical examiner training and certification process on the
National Registry Website.
Page 10 of 44
Resources on the National Registry Website
Sample Training
The Sample Training is a comprehensive example of medical examiner training. This document covers
the eight training topics in the core curriculum required by FMCSA. Training providers may modify it to
suit whatever delivery methodology they choose.
Medical Examiner Handbook
The Handbook is an online resource that provides information and guidance for medical examiners who
perform physical examinations and certifications for interstate CMV drivers.
Information Manual for Training Organizations
This manual is a complete guide to becoming a National Registry training provider. It outlines the
requirements, policies, and procedures that apply to training providers.
Administrative Manual for Testing Organizations
This is a single resource to provide testing organizations with the information needed to properly
administer the FMCSA Medical Examiner Certification Test. The manual details the requirements,
policies, and procedures for validating test takers, test administration, and transmitting results to the
National Registry.
Testing Policies and Procedures
The Day of the Test
When you arrive at the testing center, you must provide your National Registry Number, proof of your
medical credential, proof of completion of training, and one form of photo identification. At that time,
testing center personnel will verify your eligibility to take the test. If eligibility cannot be verified, you will
not be allowed to take the test.
The following are acceptable forms of identification:
•
•
•
•
•
•
•
•
•
•
U.S. driver’s license with photograph
State ID card with photograph
U.S. passport
U.S. military ID card with photograph
Permanent resident card with photograph
Native American tribal ID Card with photograph
Foreign government-issued passport with photograph
Canadian provincial driver’s license with photograph
Indian and Northern Affairs Canada card with photograph (INAC)
Transportation worker ID with photograph (TWIC)
After your eligibility is verified, the testing proctor will provide instructions on how to proceed. All FMCSAapproved testing organizations have agreed to maintain test administration and security standards.
These standards ensure that all candidates have the same opportunity to demonstrate their knowledge
and prevent testing irregularities or misconduct.
IMPORTANT: It is your responsibility to keep your contact and licensing information up to date on the
National Registry. If your license has expired or your name changes, you MUST put the correct
information into the National Registry. Be sure to update the contact (e.g. name, address, etc.) and
medical licensing information (e.g. license expires, license number, license state, etc.) you entered when
Page 11 of 44
registering on the National Registry website when there are changes. If the contact and medical licensing
information you entered during registration on the National Registry website does not match the
credentials you present to the test center, you will not be allowed to take the exam.
Security
Testing organizations approved to deliver the FMCSA Medical Examiner Certification Test have provided
FMCSA with their documented policies and procedures for ensuring test security. All tests are monitored
to ensure the highest level of security. The testing organization will provide information about their
policies and procedures at the time the test is schedule. The following security procedures generally
apply during the test:
At a test center
The testing organization must monitor every test session to maintain a standardized environment. This
ensures that every medical examiner has an equal opportunity to demonstrate his or her knowledge and
protects the integrity of the test. The following security procedures must be enforced by the person
(proctor) presenting the test.
•
•
•
No cameras, notes, documents, audio or video recorders, personal digital assistants (PDAs),
pagers, cellular phones or calculators are permitted in the testing area.
No guests, visitors or family members are allowed in the test room.
Except for keys and wallets, no personal items, including purses, business cases, backpacks,
valuables or weapons may be brought into the test room.
During testing the following apply:
•
•
•
•
•
Eating, drinking and smoking are not permitted inside the test room.
Pencils/markers may be provided and may be available during testing.
Blank scratch paper or dry-erase boards may be provided during testing, and they must be
returned to the proctor at test completion. No documents or notes of any kind may be removed
from the testing area.
The proctor may not answer any questions concerning the test content or requests for
interpretations during testing.
No conversations with others during the test (except with proctors/monitors).
Online testing
The security requirements for online testing are similar to those described for administration at a test
center. The testing organization must provide monitoring for every test session to the extent possible.
This ensures that every medical examiner has an equal opportunity to demonstrate his or her knowledge
and protects the integrity of the test. The following security procedures must be enforced by the testing
organization:
•
•
•
•
No cameras, notes, documents, audio or video recorders, PDAs, pagers, cellular phones or
calculators are permitted within view or reaching distance of the test taker.
No guests, visitors or family members are allowed in the room.
No conversations with others during the test (except with proctors/monitors).
No personal items such as purses, business cases, and backpacks are allowed within view or
reaching distance of the test taker.
During testing the following apply:
• The use of the internet, books, reference materials etc. is not permitted during the exam.
• Pencils/markers may be used.
• Blank scratch paper may be used.
• No conversations with others during the test (except with proctors/monitors).
• No telephone communications are permitted
• The candidate must remain in the room, seated at the computer within range of the webcam.
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Timed Test
The FMCSA Medical Examiner Certification Test is a two hour, timed test. The test contains 120 items;
100 are scored and 20 are being evaluated for inclusion on the test at a future date. Once the actual test
begins, the two hour test time runs continuously with no pauses.
Misconduct
Testing centers monitor for misconduct during test administration and have policies and procedures in
place for addressing the issue. Generally, candidates who engage in misconduct are dismissed from the
testing session and their scores are not reported. Testing organizations will report to FMCSA when any
applicant for FMCSA medical examiner certification engages in fraudulent means to pass the FMCSA
Medical Examiner Certification Test. FMCSA prohibits the applicant from retaking the test for 90 days.
Examples of misconduct include:
•
•
•
•
•
•
•
Creating a disturbance, is abusive or is otherwise uncooperative, and disturbs others in the test
room;
Using electronic communications equipment, such as pagers, cellular phones, or PDAs;
Giving or receiving help or is being suspected of doing so;
Attempting to record test items or makes notes;
Attempting to take the certification test for someone else;
Using notes, books, and other aids;
Talking to a person other than the proctor/monitor while taking the test.
Test Procedures
The computer tracks the time it takes to complete the test. The computer terminates the test when the
time limit is reached, regardless of whether the test is completed. Only one test item is presented at a
time, and the answers are identified as A, B, C, or D. Each test center will have its own processes that
will be explained prior to the exam.
The number of test items answered is reported at test completion. If you have not answered all questions
and time remains, you can go back and answer those questions. It is generally best to try to answer all
questions. Your score is based on the total number of correct responses.
Candidate Comments and Feedback
Testing Organizations should refrain from collecting comments about the test from candidates taking the
test. Once the candidate has completed the test, the proctor should advise them to submit comments
directly to FMCSA. The candidate should be advised that submitting a comment does not affect their
score.
Receiving Test Score/Passing the Test
The testing organization notifies the candidate that the results will be sent to FMCSA.
After receiving the test answers from the testing center, FMCSA confirms the grading, ensures the
validation of the candidate’s credentials and issues a National Registry certificate. The candidate
receives official notification via email about his or her certification status. The email includes the medical
examiner’s National Registry Number, and information about maintaining certification. Medical
examiner’s contact information will then be listed on the National Registry Website.
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Not Passing the Test
A medical examiner who does not pass the test for initial certification, recertification, or reinstatement may
take it again by submitting another application to a testing organization and paying the appropriate fee.
This is retesting. The retest does not have to be performed by the same test provider. The medical
examiner must wait 30 days before retaking the test, but there is no limit on the number of times that a
medical examiner may take the test. A medical examiner candidate must pass the certification test within
3 years after completing initial training for initial certification or for reinstatement if FMCSA requires the
medical examiner candidate to retake the initial training.
If a medical examiner listed on the National Registry fails to pass the certification test prior to the
expiration of his or her FMCSA medical examiner certification, FMCSA may issue a notice of proposed
removal to the medical examiner. If the medical examiner passes the certification test and meets all the
requirements in the notice of proposed removal, FMCSA would issue a new certification. However, if
FMCSA has removed the medical examiner from the National Registry, the medical examiner would be
required to apply for reinstatement.
Confidentiality
Individual test scores will only be reported to the individual who took the test. Aggregate scores without
personally identifiable markers will be used in collaboration with the test consultant to set the passing
points for the test and to analyze performance of individual questions.
Information provided to the National Registry may be used for analyses to study certified medical
examiners and their practice. Information-sharing will be limited to data reports that are in aggregate form
or documents that lack personally identifiable information.
Quick Reference Guide
The Quick Reference Guide to FMCSA Medical Examiner Certification and Listing on the National
Registry of Certified Medical Examiners, Appendix D of this Guide, provides a summary of the certification
and recertification processes.
Maintaining Certification
To maintain your FMCSA medical examiner certification credential, you must:
•
•
•
Be licensed, certified, and/or registered, in accordance with applicable State laws and regulations
to perform physical examinations in each state in which examinations are performed.
Complete periodic training as specified by FMCSA every 5 years, and pass the FMCSA Medical
Examiner Certification Test every 10 years.
Agree to provide proof of eligibility upon FMCSA request.
Upon successful recertification, FMCSA will issue a new FMCSA medical examiner certification credential
with a new expiration date. You will maintain the National Registry Number assigned to you at your initial
certification as long as you remain an FMCSA certified medical examiner.
You may continue to perform CMV driver physical examinations as long as your current certification has
not expired. If you have not passed the FMCSA Medical Examiner Certification Test by the expiration of
your FMCSA medical examiner certification, then you must cease performing driver exams until passing
the certification test again.
To ensure uninterrupted certification, you should complete the training requirement and pass the
certification test within 1 year prior to the certification expiration date—definitely no later than the end of
the 30-day grace period following your certification expiration date. If you do not complete successful
recertification within the 1-year (plus 30-day grace period) timeframe, the following occurs:
Page 14 of 44
•
•
•
Your certification expires;
Your information remains on the National Registry with a date of removal; and
CMV driver physical examinations performed after certification has expired are not recognized as
valid by FMCSA.
Listing on the National Registry
For initial and continued listing on the National Registry, you must successfully complete all of the
requirements for medical examiner certification and recertification defined in this Guide and summarized
in the Quick Reference Guide in Appendix D. You must report to FMCSA any changes in application
information submitted within 30 days of the change. Additionally, you must comply with the following
recordkeeping and reporting requirements.
Driver Examination Reports
Once every calendar month, each medical examiner listed on the National Registry is required to
complete and transmit to FMCSA a Form MCSA-5850, CMV Driver Medical Examination Results, with the
following information about each CMV driver examined during the previous month:
•
•
•
•
•
•
•
•
•
Name
Date of birth
Driver’s license number and State
Date of examination
An indication of the examination outcome (for example, medically qualified)
Whether the driver is an intrastate driver only
Whether the driver is a CDL holder
Date of driver medical certification expiration
Any restrictions and variances (for example, wearing corrective lenses or driving within an exempt
intra-city zone)
You must submit this data electronically via a secure FMCSA-designated website. In order to continue to
be listed on and to continue participation in the National Registry, you need to comply with this
requirement on a monthly basis. If you have not conducted any exams during the month, that must be
reported as well. Form MCSA-5850 can be found as Appendix E of this Guide.
Performance Monitoring
Medical examiners must provide Medical Examination Reports and medical examiner’s certificates to an
authorized representative, special agent, or investigator of FMCSA or an authorized State or local
enforcement agency representative to ensure compliance with FMCSA medical standards and guidelines
in performing CMV driver medical examinations. FMCSA monitors medical examiner performance by:
•
Conducting periodic reviews of randomly selected medical examiners listed on the National
Registry Website to ensure that CMV driver examinations are being conducted properly.
•
Periodically reviewing a representative sample of the Medical Examination Reports associated
with the name and numerical identifiers of applicants/drivers for errors, omissions, or other
indications of improper certification.
To comply with performance monitoring, you must:
•
Retain each original (paper or electronic) completed Medical Examination Report and a copy or
electronic version of each medical examiner's certificate on file for at least 3 years from the date
of the of examination.
Page 15 of 44
•
Make all records and information in these files available to an authorized representative of
FMCSA or an authorized Federal, State, or local enforcement agency representative, within 48
hours after the request is made for investigations and within 10 days of requests for regular
audits.
Auditing
FMCSA will conduct annual medical examiner audits. The purpose of the audit is to check a percentage
of medical examiners listed on the National Registry Website to obtain verification of eligibility (e.g., proof
of current State medical licensure, registration, or certification to perform physical examinations and proof
of completion of required training).
To comply with auditing requirements, you must:
•
Maintain documentation of State licensure, registration, or certification to perform physical
examinations for each State in which you perform examinations.
•
Maintain documentation of completion of all required training.
•
Make documentation available to an authorized representative of FMCSA or other authorized
representative of Federal, State, or local government within 48 hours of the request for
investigations and within 10 days of the request for regular audits of eligibility.
Removal from the National Registry
FMCSA may remove a medical examiner from the National Registry when the medical examiner fails to
meet or maintain the qualifications outlined in this Guide, the requirements of other Federal regulations
applicable to the medical examiner, or does not meet the requirements of 49 U.S.C. 31149.
Reasons for Removal
The reasons for removal may include, but are not limited to:
•
•
•
•
•
Failure of the medical examiner to comply with the requirements for continued listing on the
National Registry as described in this Guide.
FMCSA discovers that the medical examiner has made errors or omissions or finds other
indications of improper certification in either the completed Medical Examination Reports or
medical examiner’s certificates.
FMCSA determines that the medical examiner issued a medical examiner's certificate to an
operator of a CMV who failed to meet the applicable standards at the time of the examination.
Failure of the medical examiner to comply with FMCSA driver examination requirements.
Failure of the medical examiner to complete training in physical and medical examination standards.
Procedure for Removal
Voluntary Removal
To be removed voluntarily from the National Registry, a medical examiner must submit a request to
FMCSA via web account. FMCSA will accept the request and the removal will become effective
immediately. However, on and after the date of issuance of a notice of proposed removal from the
National Registry, FMCSA will not approve the medical examiner’s request for voluntary removal. A
medical examiner requesting voluntary removal should submit a final FMCSA Form MCSA-5850 before
the removal takes effect.
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Involuntary Removal: Notice of Proposed Removal
FMCSA initiates the process for involuntary removal of a medical examiner from the National Registry by
issuing a written notice of proposed removal to the medical examiner, stating the reasons that removal is
proposed and any corrective actions necessary for the medical examiner to remain listed on the National
Registry.
Response to Notice of Proposed Removal and Corrective Action
A medical examiner who has received a notice of proposed removal must submit any written response to
FMCSA via web account no later than 30 days after the date of issuance of the notice of proposed
removal. The response must indicate either that the medical examiner believes FMCSA has relied on
erroneous reasons, in whole or in part, in proposing removal from the National Registry, or that the
medical examiner will comply and take any corrective action specified in the notice of proposed removal.
Opposing a Notice of Proposed Removal
If a medical examiner believes FMCSA to have proposed removal based in whole or in part on an
erroneous reason, the medical examiner must explain the situation. FMCSA will review the explanation.
o Withdraw Notice: If FMCSA determines that the reason for proposing removal from the
National Registry is an error, FMCSA will withdraw the notice of proposed removal and notify
the medical examiner, in writing, of the determination. If FMCSA determines reliance on a
partly erroneous reason for proposing removal from the National Registry, FMCSA will modify
the notice of proposed removal and notify the medical examiner, in writing, of the
determination. The medical examiner must comply and correct the deficiencies identified in
the modified notice of proposed removal no later than 60 days after the date FMCSA modifies
a notice of proposed removal.
o Affirm Notice: If FMCSA determines there was no reliance on an erroneous reason in
proposing removal, FMCSA will affirm the notice of proposed removal and notify the medical
examiner, in writing, of the determination. No later than 60 days after the date FMCSA
affirms the notice of proposed removal, the medical examiner must comply and correct the
deficiencies identified in the notice of proposed removal.
o Removal: If the medical examiner does not submit a written response within 30 days of the
date of issuance of a notice of proposed removal, the removal becomes effective, and the
medical examiner is immediately removed from the National Registry.
Compliance and Corrective Action
o Compliance: The medical examiner must comply and complete the corrective actions
specified in the notice of proposed removal no later than 60 days after either the date of
issuance of the notice of proposed removal or the date FMCSA affirms or modifies the notice
of proposed removal, whichever is later. The medical examiner must provide documentation
of compliance and completion of the corrective actions to FMCSA. FMCSA may conduct any
investigations and request any documentation necessary to verify that the medical examiner
has complied and completed the required corrective action(s). FMCSA will notify the medical
examiner, in writing, whether he or she has met the requirements to continue to be listed on
the National Registry.
o Failure to Comply: If the medical examiner fails to complete the proposed corrective
action(s) within the 60-day period, the removal becomes effective and the medical examiner
is immediately removed from the National Registry. FMCSA will notify the medical examiner,
in writing, that he or she has been removed from the National Registry.
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o Resolution: At any time before a notice of proposed removal from the National Registry
becomes final, the medical examiner who received the notice and FMCSA may resolve the
matter by mutual agreement.
Request for an Administrative Review
If a medical examiner has been removed from the National Registry, the medical examiner may request
an administrative review no later than 30 days after the date the removal becomes effective. The request
must be submitted in writing to the FMCSA Associate Administrator for Policy and must explain the
error(s) committed in removing the medical examiner from the National Registry, including a list of all
factual, legal, and procedural issues in dispute and any supporting information or documents.
o Additional Procedures for an Administrative Review: The Associate Administrator may
ask the medical examiner to submit additional data or attend a conference to discuss the
removal. If the medical examiner does not provide the information requested, or does not
attend the scheduled conference, the Associate Administrator may dismiss the request for
administrative review.
o Decision on Administrative Review: The Associate Administrator will complete the
administrative review and notify the medical examiner, in writing, of the decision. The
decision represents final Agency action. If the Associate Administrator decides the removal
was not valid, FMCSA will reinstate the medical examiner and reissue a certification
credential to expire on the expiration date of the certificate that was invalidated. The
reinstated medical examiner must continue to meet all requirements defined in this Guide.
Emergency Removal
In cases of either willfulness or in which public health, interest, or safety is an issue, the provisions of this
section are not applicable and FMCSA may immediately remove a medical examiner from the National
Registry and invalidate the FMCSA medical examiner certification credential issued. A medical examiner
who has been removed may request an administrative review of that decision.
Reinstatement on the National Registry
A medical examiner who has been removed from the National Registry may apply to FMCSA for
reinstatement no sooner than 30 days after the date of removal. The former medical examiner must
provide documentation showing compliance with all requirements and completion of any additional
corrective actions required in the notice of proposed removal. A medical examiner who has been
voluntarily removed may be reinstated by FMCSA after providing documentation showing proof of
compliance with all requirements.
Effect of Final Decision by FMCSA
Once removed from the National Registry, the medical examiner’s listing is removed and the FMCSA
medical examiner certification credential is no longer valid. The medical examiner’s information remains
publicly available for 3 years, with an indication that he/she is no longer listed on the National Registry as
of the date of removal.
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Appendices
Appendix A: National Registry of Certified Medical Examiners Medical Examiner
Training, Guidance for the Core Curriculum Specifications
The guidance for the core curriculum specifications is intended to assist training organizations in
developing programs that would be used to fulfill the proposed requirements in the Federal Motor Carrier
Safety Administration’s (FMCSA) rule for the National Registry of Certified Medical Examiners (National
Registry). The rule states that a medical examiner must complete a training program. FMCSA explained
in the preamble to the rule that training providers and organizations must follow the core curriculum
specifications in developing training programs for medical examiners who apply for listing on the Agency’s
National Registry. This training prepares medical examiners to:
•
Apply knowledge of FMCSA’s driver physical qualifications standards and advisory criteria to
findings gathered during the driver’s medical examination; and
•
Make sound determinations of the driver’s medical and physical qualifications for safely operating
a commercial motor vehicle (CMV) in interstate commerce.
The rule, 49 CFR 390.105(b), lists eight topics which must be covered in the core curriculum
specifications. The core curriculum specifications are arranged below by numbered topic, followed by
guidance to assist training providers in developing programs based on the core curriculum specifications.
Guidance for Each of the Core Curriculum Specifications
(1) Background, rationale, mission and goals of the FMCSA medical examiner’s role in reducing
crashes, injuries and fatalities involving commercial motor vehicles.
Mission and Goals of Federal Motor Carrier Safety Administration (FMCSA)
•
Discuss the history of FMCSA and its position within the Department of Transportation including
its establishment by the Motor Carrier Safety Improvement Act of 1999 and emphasize FMCSA’s
Mission to reduce crashes, injuries and fatalities involving large trucks and buses.
Role of the Medical Examiner
•
Explain the role of the medical examiner as described in 49 CFR 391.43.
(2) Familiarization with the responsibilities and work environment of commercial motor vehicle
(CMV) operations.
The Job of CMV Driving
•
Describe the responsibilities, work schedules, physical and emotional demands and lifestyle
among CMV drivers and how these vary by the type of driving.
•
Discuss factors and job tasks that may be involved in a driver’s performance, such as:
o Loading and unloading trailers;
o Inspecting the operating condition of the CMV; and
o Work schedules:
− Irregular work, rest, and eating patterns / dietary choices.
Page 19 of 44
(3) Identification of the driver and obtaining, reviewing, and documenting driver medical history,
including prescription and over-the-counter medications.
Driver Identification and Medical History:
Discuss the importance of driver identification and review of the following elements of the driver’s medical
history as related to the tasks of driving a CMV in interstate commerce.
•
Inspect a State-issued identification document with the driver’s photo to verify the identity of the
individual being examined; identify the commercial driver’s license or other types of driver’s license.
•
Identify, query and note issues in a driver’s medical record and/or health history as available, which
may include:
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
o
specific information regarding any affirmative responses in the history;
any illness, surgery, or injury in the last five years;
any other hospitalizations or surgeries;
any recent changes in health status;
whether he/she has any medical conditions or current complaints;
any incidents of disability / physical limitations;
current medications and supplements, and potential side effects, which may be potentially
disqualifying;
his/ her use of recreational/addictive substances (e.g., nicotine, alcohol, inhalants, narcotics
or other habit-forming drugs);
disorders of the eyes (e.g., retinopathy, cataracts, aphakia, glaucoma, macular degeneration,
monocular vision);
disorders of the ears (e.g., hearing loss, hearing aids, vertigo, tinnitus, implants);
cardiac symptoms and disease (e.g., syncope, dyspnea, chest pain, palpitations,
hypertension, congestive heart failure, myocardial infarction, coronary insufficiency, or
thrombosis);
pulmonary symptoms and disease (e.g., dyspnea, orthopnea, chronic cough, asthma, chronic
lung disorders, tuberculosis, previous pulmonary embolus, pneumothorax);
sleep disorders (e.g., obstructive sleep apnea, daytime sleepiness, loud snoring, other);
gastrointestinal disorders (e.g., liver disease, digestive problems, hernias);
genitourinary disorders (e.g., kidney stones and other renal conditions, renal failure, hernias);
diabetes mellitus:
 current medications (type, potential side effects, duration on current medication);
 complications from diabetes; and
 presence and frequency of hypoglycemic / hyperglycemic episodes/reactions;
other endocrine disorders (e.g., thyroid disorders, interventions / treatment);
musculoskeletal disorders (e.g., amputations, arthritis, spinal surgery);
neurologic disorders (e.g., loss of consciousness, seizures, stroke / transient ischemic attack,
headaches/ migraines, numbness / weakness) ; or
psychiatric disorders (e.g., schizophrenia, severe depression, anxiety, bipolar disorder, or
other conditions) that could impair a driver’s ability to safely function.
(4) Performing, reviewing and documenting the driver’s medical examination.
Physical Examination (Qualification/Disqualification Standards (§ 391.41 and 391.43))
•
Explain the FMCSA physical examination requirements and advisory criteria in relationship to
conducting the driver’s physical examination of the following:
o Eyes (§ 391.41(b)(10))
 equal reaction of both pupils to light;
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

evidence of nystagmus and exophthalmos;
evaluation of extra-ocular movements.
o Ears (§ 391.41(b)(11))
 abnormalities of the ear canal and tympanic membrane;
 presence of a hearing aid.
o Mouth and throat (§ 391.41(b)(5))
 conditions contributing to difficulty swallowing, speaking or breathing;
o Neck (§ 391.41(b)(7))
 range of motion;
 soft tissue palpation / examination (e.g., lymph nodes, thyroid gland).
o Heart (§ 391.41(b)(4)and (b)(6))
 chest inspection (e.g., surgical scars, pacemaker / implantable automatic
defibrillator);
 auscultation for thrills, murmurs, extra sounds, and enlargement;
 blood pressure and pulse (rate and rhythm);
 additional signs of disease (e.g., edema, bruits, diaphoresis, distended neck
veins.
o Lungs, chest, and thorax (§ 391.41(b)(5))
 respiratory rate and pattern;
 auscultation for abnormal breath sounds;
 abnormal chest wall configuration / palpation.
o Abdomen (§ 391.41(a)(3)(i) and 391.43(f))
 surgical scars;
 palpation for enlarged liver or spleen, abnormal masses or bruits / pulsation,
abdominal tenderness, hernias (e.g., inguinal, umbilical, ventral, femoral or other
abnormalities).
o Spine (§ 391.41(b)(7))
 surgical scars and deformities;
 tenderness and muscle spasm;
 loss in range of motion and painful motion;
 spinal deformities.
o Extremities and trunk (§ 391.41(b)(1), (b)(4) and (b)(7))
 gait, mobility, and posture while bearing his/her weight; limping or signs of pain;
 loss, impairment, or use of orthosis;
 deformities, atrophy, weakness, paralysis, or surgical scars;
 elbow and shoulder strength, function, and mobility;
 handgrip and prehension relative to requirements for controlling a steering wheel
and gear shift;
 varicosities, skin abnormalities, and cyanosis, clubbing, or edema;
 leg length discrepancy; lower extremity strength, motion, and function
 other abnormalities of the trunk.
o Neurologic status (§ 391.41(b)(7), (b)(8) and(b)(9))
 impaired equilibrium, coordination or speech pattern (e.g., ataxia);
 sensory or positional abnormalities;
 tremor;
 radicular signs;
 reflexes (e.g., asymmetric deep-tendon, normal / abnormal patellar and
Babinski).
Page 21 of 44
o Mental status (§ 391.41(b)(9))
 comprehension and interaction;
 cognitive impairment;
 signs of depression, paranoia, antagonism, or aggressiveness that may require
follow-up with a mental health professional.
(5) Performing, obtaining and documenting diagnostic tests and obtaining additional testing or
medical opinion from a medical specialist or treating physician.
Diagnostic Testing and Further Evaluation
•
Describe the FMCSA diagnostic testing requirements and the medical examiner’s ability to
request further testing and evaluation by a specialist.
o Urine test for specific gravity, protein, blood and glucose (§ 391.41(a)(3)(i));
o Whisper or audiometric testing (§ 391.41(b)(11));
o Vision testing for color vision, distant acuity, horizontal field of vision and presence of
monocular vision
(§ 391.41(b)(10));
o Other testing as indicated to determine the driver’s medical and physical qualifications for
safely operating a CMV.
o Refer to a specialist a driver who exhibits evidence of any of the following disorders (§
391.43(e) and (f)):
 vision (e.g., retinopathy, macular degeneration);
 cardiac (e.g., myocardial infarction, coronary insufficiency, blood pressure
control);
 pulmonary (e.g., emphysema, fibrosis);
 endocrine (e.g., diabetes);
 musculoskeletal (e.g., arthritis, neuromuscular disease);
 neurologic (e.g., seizures);
 sleep (e.g., obstructive sleep apnea);
 mental / emotional health (e.g., depression, schizophrenia); or
 other medical condition(s) that may interfere with ability to safely operate a CMV.
(6) Informing and educating the driver about medications and non-disqualifying medical
conditions that require remedial care.
Health Counseling
•
Inform course participants of the importance of counseling the driver about:
o possible consequences of non-compliance with a care plan for conditions that have been
advised for periodic monitoring with primary healthcare provider;
o possible side effects and interactions of medications (e.g., narcotics, anticoagulants,
psychotropics) including products acquired over-the-counter (e.g., antihistamines, cold
and cough medications or dietary supplements ) that could negatively affect his/her
driving;
o the effect of fatigue, lack of sleep, poor diet, emotional conditions, stress, and other
illnesses that can affect safe driving;
o if he/she is a contact lens user, the importance of carrying a pair of glasses while driving;
o if he/she uses a hearing aid, the importance of carrying a spare power source for the
device while driving;
o if he/she has a history of deep vein thrombosis, the risk associated with inactivity while
driving and interventions that could prevent another thrombotic event;
o if he/she has a diabetes exemption, that he/she should:
 carry a rapidly absorbable form of glucose while driving;
Page 22 of 44

self-monitor blood glucose one hour before driving and at least once every four
hours while driving;
 comply with each condition of his/her exemption;
 plan to submit glucose monitoring logs for each annual recertification;
o corrective or therapeutic steps needed for conditions which may progress and adversely
impact safe driving ability (e.g., seek follow-up from primary care physician);
o steps needed for reconsideration of medical certification if driver is certified with a limited
interval, e.g., the return date and documentation required for extending the certification
time period.
(7) Determining driver certification outcome and period for which certification should be valid.
Assessing the Driver’s Qualifications and Disposition
•
Explain how to assess the driver’s medical and physical qualification to operate a CMV safely in
interstate commerce using the medical examination findings weighed against the physical and
mental demands associated with operating a CMV by:
o Considering a driver’s ability to







move his/her body through space while climbing ladders; bend, stoop, and
crouch; enter and exit the cab;
manipulate steering wheel;
perform precision prehension and power grasping;
use arms, feet, and legs during CMV operation;
inspect the operating condition of a tractor and/or trailer;
monitor and adjust to a complex driving situation; and
consider the adverse health effects of fatigue associated with extended work
hours without breaks;
o Considering identified disease or condition(s) progression rate, stability, and likelihood of
gradual or sudden incapacitation for documented conditions (e.g., cardiovascular,
neurologic, respiratory, musculoskeletal and other).
Medical Certificate Qualification/Disqualification Decision and Examination Intervals
•
Discuss the medical examiner’s obligation to consider potential risk to public safety and the
driver’s medical and physical qualifications to drive safely when issuing a medical examiner’s
certificate, when to qualify/disqualify the driver and how to determine the expiration date of the
certificate by:
o using the requirements stated in the FMCSRs, with nondiscretionary certification
standards to disqualify a driver
 with a history of epilepsy;
 with diabetes requiring insulin control (unless accompanied by an exemption);
 when vision parameters (e.g., acuity, horizontal field of vision, color) fall below
minimum standards unless accompanied by an exemption;
 when hearing measurements with or without a hearing aid fall below minimum
standards;
 currently taking methadone;
 with a current clinical diagnosis of alcoholism; or
 who uses a controlled substance including a narcotic, an amphetamine, or
another habit-forming drug without a prescription from the treating physician;
o using clinical expertise, disqualify a driver when evidence shows a driver has a medical
condition that in your opinion will likely interfere with the safe operation of a CMV;
Page 23 of 44
o certifying a driver for an appropriate duration of certification interval;
o if he/she has a condition for which the medical examiner is deferring the driver’s medical
certification or disqualifying the driver, informing the driver of the reasons which may
include:
 a vision deficiency (e.g., retinopathy, macular degeneration);
 the immediate post-operative period;
 a cardiac event (e.g., myocardial infarction, coronary insufficiency);
 a chronic pulmonary exacerbation (e.g., emphysema, fibrosis);
 uncontrolled hypertension;
 endocrine dysfunctions (e.g., insulin-dependent diabetes);
 musculoskeletal challenges (e.g., arthritis, neuromuscular disease);
 a neurologic event (e.g., seizures, stroke, TIA);
 a sleep disorder (e.g., obstructive sleep apnea); or
 mental health dysfunctions (e.g., depression, bipolar disorder).
(8) FMCSA reporting and documentation requirements.
Documentation of Medical Examination Findings
Demonstrate the required FMCSA medical examination report forms, appropriate methods for recording
the medical examination findings and the rationale for certification decisions including:
•
Medical Examination Report Form
o identification of the driver;
o use of appropriate Medical Examination Report form;
o assurance that driver completes and signs driver’s portion of the Medical Examination
Report form;
o specifics regarding any affirmative response on the driver’s medical history;
o height/weight, blood pressure, pulse;
o results of the medical examination, including details of abnormal findings;
o audiometric and vision testing results;
o presence of a hearing aid and whether it is required to meet the standard;
o if obtained, funduscopic examination results;
o the need for corrective lenses for driving;
o presence or absence of monocular vision and need for a vision exemption;
o if driver has diabetes mellitus and is insulin dependent, the need for a diabetes
exemption;
o other laboratory, pulmonary, cardiac testing performed; and o the reason(s) for the disqualification and/or referral.
•
Other supporting documentation
o if driver has current vision exemption, include the ophthalmologist’s or optometrist’s
report;
o if a driver has a diabetes exemption, include the endocrinologist’s and
ophthalmologist’s/optometrist’s report;
o treating physician’s work release;
o if obtained, specialist’s evaluation report;
o if the driver has a current Skill Performance Evaluation Certificate, include it; and
o results of Substance Abuse Professional evaluations for alcohol and drug use and/or
abuse for a driver with
 alcoholism who completed counseling and treatment to the point of full recovery.
•
Medical Examiner’s Certificate
o certification status, which may require:
 waiver / exemption;
 wearing corrective lenses;
Page 24 of 44
 wearing a hearing aid; or
 a Skill Performance Evaluation Certificate;
o complete and accurate documentation on medical certification card including:
 the examiner’s name, examination date, office address, and telephone number
and Medical Examiner signature; and
 the driver’s signature.
Page 25 of 44
Appendix B: Detailed Content Outline
Using the Detailed Content Outline
Items on the certification test are limited to what the detailed content outline describes, which should
make the outline a useful guide for preparing oneself to take the test. The outline contains several pieces
of information about the test. Included in this information are answers to the following questions:
•
•
•
What competencies can the test cover?
What type of content does the test emphasize?
How complex will test items be?
A review of information from the first page of the outline can help one to understand these points.
The first (of two) major content domains (indicated with a roman numeral I) will cause the test to assess
medical examiners’ competencies while they interact with medical information from drivers. Seventy items
on the test will assess this type of content. The major domain is subdivided into minor domains (indicated
with Arabic letters A, B and so on).
Items covering content in each domain are subdivided among three levels of cognitive complexity. These
levels range from simple items based on facts that a medical examiner should have memorized to
scenarios describing complicated medical histories. The simple test items focusing on memorized facts
are characterized with a label called Recall. The complicated items assessing abilities to solve problems
are characterized with a label called Analysis. Between these two types are Application items. These
moderately complex items focus on conclusions medical examiners reach about medical information they
encounter.
Lastly, by studying each row of the table, a medical examiner will learn that the complexity of
assessments of some competencies will be limited. For example, the competency (I.A.2.) in which a
medical examiner ensures the driver signs the statement about his or her health history is limited to the
recall type of item. Assessment of the competency labeled as I.A.1., which relates to verifying the driver’s
identity could involve the recall-type or application-type of item. The competency labeled as 1.A.3.a. could
be assessed with items at any of the three levels of cognitive complexity.
Page 26 of 44
Medical examiners are encouraged to study the entire outline so they may understand the nature of the
items that could appear on the version of the test that he or she takes. Each version is assembled
according to the specifications shown in the outline regarding the number of items from each domain and
level of cognition.
Items
Cognitive
Level
1. Verify the identity of the driver
2. Ensure the driver signs the driver’s statement about health history
3. Identify, query, and note issues in a driver’s medical record and / or health history
Totals
Analysis
Open cells show an examination could include items from indicated cognitive levels.
Shaded cells prevent appearance of items on examinations.
Application
Recall
National Registry of Certified Medical Examiners (The National Registry)
FMCSA Medical Examiner
Detailed Content Outline
23 33 14 70
4
6
10 20
as available, which may include
a. specifics regarding any affirmative responses in the history
b. any illness, surgery, or injury in the last five years
c. any other hospitalizations or surgeries
d. any recent changes in health status
e. whether he / she has any medical conditions or current complaints
f. any incidents of disability / physical limitations
g. limitations placed during prior FMCSA exams
h. current OTC and prescription medications and supplements, and potential
side effects, which may be potentially disqualifying
i. his or her use of recreational / addictive substances (e.g., nicotine, alcohol,
inhalants)
j. weight disorders (e.g., unexplained loss or gain, obesity)
k. disorders of the eyes (e.g., retinopathy, cataracts, aphakia, glaucoma,
macular degeneration, monocular vision)
l. disorders of the ears (e.g., hearing loss, hearing aids, vertigo, Meniere’s,
tinnitus, implants)
m. cardiac symptoms (e.g., syncope, dyspnea, chest pain, palpitations)
n. cardiovascular diseases (e.g., hypertension, congestive heart failure,
myocardial infarction, coronary insufficiency, or thrombosis)
o. hematologic disorders (e.g., bleeding disorders, anemia, cancer, organ
transplant history)
p. pulmonary symptoms (e.g., dyspnea, orthopnea, chronic cough)
q. pulmonary diseases (e.g., asthma, chronic lung disorders, tuberculosis,
previous pulmonary embolus, pneumothorax)
r. sleep disorders (e.g., sleep apnea, narcolepsy, insomnia, daytime
sleepiness, loud snoring, testing and / or treatments)
s. gastrointestinal disorders (e.g., pancreatitis, ulcers, ulcerative colitis,
cirrhosis, hepatitis, irritable bowel syndrome, hernias)
Page 27 of 44
Items
Cognitive
Level
Recall
Application
Analysis
Totals
8
15
2
25
t. genitourinary disorders (e.g., polycystic, nephrotic syndrome, kidney stones,
renal failure, hernias)
u. diabetes mellitus
 weight loss
 duration on current medications
 medication side effects
 complications from diabetes
 availability of emergency glucose supply
 presence and frequency of hypoglycemic / hyperglycemic episodes /
reactions
v. other endocrine disorders (e.g., thyroid disorders, interventions / treatment)
w. musculoskeletal disorders (e.g., amputations, arthritis, spinal surgery)
x. neoplastic disorders (e.g., leukemia; brain, bone, breast, and lung cancer)
y. substance use and abuse (e.g., alcohol, narcotics, illicit or legal drugs)
z. neurologic disorders (e.g., loss of consciousness, seizures, stroke / TIA,
headaches / migraines, numbness / weakness)
aa. psychiatric disorders (e.g., schizophrenia, depression, anxiety, bipolar,
ADHD, interventions / treatment)
bb. other conditions that could impair a driver’s ability to safely function
1. Ensure the driver is properly clothed for the physical examination
2. Record height and weight, and note whether a driver is overweight or
underweight
3. Examine the driver’s eyes and note
a. distant acuity in each and both eyes (Snellen comparable values)
b. whether corrective lenses are required to meet the standard
c. horizontal field of vision in each eye
d. color recognition
e. presence or absence of monocular vision
f. reactivity to light and pupillary equality
g. evidence of nystagmus and exophthalmos
h. evaluation of extraoccular movements
i. fundoscopic examination results
4. Examine the driver’s ears and note
a. abnormalities of the ear canal and tympanic membrane
b. whisper test and / or audiometric results (in ANSI standard units) as
indicated
c. presence or absence of a hearing aid and whether required to meet the
standard
5. Examine the driver’s mouth and throat, and note conditions that may interfere
with breathing, speaking, or swallowing
Page 28 of 44
Items
Cognitive
Level
6. Examine the driver’s neck and note
a. range of motion
b. soft tissue palpation / examination (e.g., lymph nodes, thyroid gland)
7. Examine the driver’s heart
a. chest inspection (e.g., surgical scars, pacemaker / IAD)
b. thrills, murmurs, extra sounds, and enlargement
c. blood pressure and pulse (rate and rhythm)
d. additional signs of disease (e.g., edema, bruits, diaphoresis, distended neck
8.
9.
10.
11.
12.
veins)
Examine the driver’s lungs, chest, and thorax, excluding breasts, and note
a. respiratory rate and pattern
b. abnormal breath sounds
c. abnormal chest wall configuration / palpation
d. scars
Examine the driver’s abdomen, and note
a. surgical scars
b. an enlarged liver or spleen
c. abnormal masses or bruits / pulsation
d. abdominal tenderness
e. hernias (e.g., inguinal, umbilical, ventral, femoral)
Examine the driver’s spine and note
a. surgical scars and deformities
b. tenderness and muscle spasm
c. loss in range of motion and painful motion
d. kyphosis, scoliosis, or other spinal deformities
Examine the driver’s extremities and note
a. gait, mobility, and posture while bearing his or her weight; limping or signs of
pain
b. loss, impairment, or use of orthosis
c. deformities, atrophy, weakness, paralysis, surgical scars,
d. elbow and shoulder strength, function, and mobility
e. handgrip and prehension relative to requirements for controlling a steering
wheel and gear shift
f. varicosities, skin abnormalities, and cyanosis, clubbing, or edema
g. leg length discrepancy; lower extremity strength, motion, and function
Examine the driver’s neurologic status and note
a. impaired equilibrium, coordination or speech pattern (e.g., Romberg, finger to
nose test)
b. gait disorders
c. sensory or positional abnormalities
Page 29 of 44
Totals
Analysis
Application
Recall
Items
Cognitive
Level
Recall
Application
Analysis
Totals
6
10
2
18
d. tremor
e. radicular signs
f. reflexes (e.g., asymmetric deep-tendon, normal / abnormal patellar and
Babinski
13. Test the driver’s urine and note specific gravity, protein, blood, and glucose
14. Examine the driver’s mental status and note
a. comprehension and interaction
b. cognitive impairment (e.g., orientation, intellect, memory, obsessions,
circumstantial / tangential speech)
c. signs of depression, paranoia, antagonism, or aggressiveness that may
require follow-up with a mental health professional
C. Diagnostic Tests and / or Referrals
1. Obtain additional information when indicated by
a. audiometrics
b. cardiovascular studies (e.g., electrocardiogram, stress test, ejection fraction,
vascular studies)
c. blood analyses (e.g., creatinine, electrolytes, toxicology, lipids, blood
chemistries)
d. chest radiograph
e. respiratory tests (e.g., spirometry, diffusion, lung volumes, oximetry or
arterial blood gas analysis with or without exercise)
f. sleep studies
g. drug level monitoring (e.g., digoxin, theophylline)
h. other tests
2. Refer a driver who exhibits evidence of any of the following disorders for followup care and evaluation by an appropriate specialist or primary care provider
 vision (e.g., retinopathy, macular degeneration)
 cardiac (e.g., myocardial infarction, coronary insufficiency, blood pressure
control)
 pulmonary (e.g., emphysema, fibrosis)
 endocrine (e.g., diabetes)
 musculoskeletal (e.g., arthritis, neuromuscular disease)
 neurologic (e.g., seizures)
 sleep (e.g., obstructive sleep apnea)
 mental / emotional health (e.g., depression, schizophrenia)
3. Refer a driver
a. with limitations in extremity movement for an on-road performance
evaluation and / or skill performance evaluation
b. for conditions not directly related to certification, but detected during the
examination
Page 30 of 44
Items
Cognitive
Level
Recall
Application
Analysis
Totals
5
2
0
7
7
12 11 30
2
1
D. Documentation of Ancillary Information
1. Record / include results as available with other information about the driver,
2.
3.
4.
5.
6.
which may include
a. audiometrics
b. cardiovascular studies (e.g., electrocardiogram, stress test, ejection fraction,
vascular studies)
c. blood analyses (e.g., creatinine, electrolytes, toxicology, lipids, blood
chemistries)
d. chest radiograph
e. respiratory tests (e.g., spirometry, diffusion, lung volumes, oximetry or
arterial blood gas analysis with or without exercise)
f. sleep studies
g. drug level monitoring (e.g., digoxin, theophylline)
h. other tests
i. treating physician’s work release
Integrate a specialist’s evaluation with other information about the driver
For a driver who was qualified under a vision exemption, include an annual
ophthalmologist’s or optometrist’s report
For a driver who is qualified under a diabetes exemption, include an
endocrinologist’s and ophthalmologist’s / optometrist’s report as required
Include if available
a. a current skill performance evaluation certificate
b. documentation of intra-city zone exemption
Review results of SAP evaluations for alcohol and drug use and / or abuse for a
driver with
a. alcoholism who completed counseling and treatment to the point of full
recovery
b. prohibited drug use who shows evidence he or she is now free from such
use
II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION
A. Health Education Counseling
1. Explain to a driver consequences of non-compliance with a care plan for
1
conditions that have been advised for periodic monitoring with primary healthcare
provider
2. Advise a driver
a. regarding side effects and interactions of medications and supplements
(e.g., narcotics, anticoagulants, psychotropics) including those acquired over
the counter (e.g., antihistamines, cold and cough medications) that could
negatively affect his or her driving
Page 31 of 44
4
Items
Cognitive
Level
Recall
Application
Analysis
Totals
2
4
8
14
b. that fatigue, lack of sleep, undesirable diet, emotional conditions, stress, and
other illnesses can affect safe driving
c. with contact lenses he or she should carry a pair of glasses while driving
d. with a hearing aid he / she should possess a spare power source for the
device while driving
e. who has had a deep vein thrombosis event of risks associated with inactivity
while driving and interventions that could prevent another thrombotic event
f. who has diabetes about glucose monitoring frequencies and the minimum
threshold while driving
g. with a diabetes exemption, he / she should
1) possess a rapidly absorbable form of glucose while driving
2) self-monitor blood glucose one hour before driving and at least once
every four hours while driving
3) comply with each condition of his / her exemption
4) plan to submit glucose monitoring logs for each annual recertification
3. Inform the driver of the rationale for delaying or potentially disqualifying
certification, which may include
 the immediate post-operative period after certain procedures
 a vision impairment (e.g., retinopathy, macular degeneration)
 a cardiac event (e.g., myocardial infarction, coronary insufficiency)
 a chronic pulmonary exacerbation (e.g., emphysema, fibrosis)
 uncontrolled hypertension
 endocrine dysfunction (e.g., diabetes)
 musculoskeletal challenges (e.g., arthritis, neuromuscular disease)
 a neurologic event (e.g., seizures, stroke, TIA)
 a sleep disorder (e.g., obstructive sleep apnea)
 mental health dysfunctions (e.g., depression, bipolar)
 postoperative complication
B. Risk Assessment
1. Consider a driver’s ability to
 couple and uncouple trailers from a tractor
 load or unload several thousand pounds of freight
 install and remove tire chains
 manipulate and secure tarpaulins that cover open trailer
 move one’s own body through space while climbing ladders; bending,
stooping, and crouching; entering and exiting the cab
 manipulate an oversized steering wheel
 shift through several gears using a manual transmission
 perform precision prehension and power grasping
 use arms, feet, and legs during CMV operation
Page 32 of 44
Items
Cognitive
Level
Recall
Application
Analysis
Totals
3
7
2
12
2. Review Skill Performance Evaluation (SPE) cases
a. identify terms, conditions, and limitations set forth in a driver’s SPE
Certificate
b. For a driver who lost a foot, leg, hand, or arm, ensure that an appropriate
SPE Certificate from the FMCSA Division Administrator has been granted
3. Consider a driver’s cognitive ability to
 plan a travel route
 inspect the operating condition of a tractor and / or trailer
 monitor and adjust to a complex driving situation
 maneuver through crowded areas
 quickly alter the course of vehicle to avoid trouble
4. Consider general health and wellness factors such as
a. adverse health effects associated with rotating work schedules and irregular
sleep patterns
b. long-term effects of fatigue associated with extended work hours without
breaks
c. risk factors associated with poor dietary choices
d. stressors likely to be associated with extended time away from a driver’s
social support system
e. short- and long-term health effects of stress from
 tight pickup and delivery schedules
 irregular work, rest, and eating patterns / dietary choices
 adverse road, weather, and traffic conditions
 exposure to temperature extremes, vibration, and noise
 transporting passengers or hazardous products
5. Integrate FMCSA medical advisory criteria and guidelines regarding a driver’s
condition into the risk assessment
6. Consider the rate of progression, degree of control, and likelihood of sudden
incapacitation (e.g., cardiovascular, neurologic, respiratory, musculoskeletal) for
documented conditions
7. Support the rationale for using FMCSA guidelines that have not been published
in regulations yet
1. As appropriate, certification standards to disqualify a driver
a. with a history of epilepsy or other seizure history
b. with insulin-treated diabetes mellitus (unless accompanied by an exemption)
c. when vision parameters (e.g., acuity, horizontal field of vision, color) fall
below minimum standards unless accompanied by an exemption
d. when hearing measurements with or without a hearing aid fall below
minimum standards
2. Disqualify a driver who
a. is currently taking methadone
Page 33 of 44
Items
Cognitive
Level
Totals
Analysis
Application
Recall
b. has a current clinical diagnosis of alcoholism
c. uses a controlled substance including a narcotic, an amphetamine, or
3.
4.
5.
6.
7.
8.
9.
another habit-forming drug without a prescription from the treating physician,
or as appropriate
Disqualify a driver when evidence shows a condition or treatment that will likely
interfere with the safe operation of a CMV, which may include appropriate
supporting documents such as test reports, specialist reports etc.
Document the reason(s) for the disqualification and / or referral
Advise a driver of the reasons for a disqualification decision and what a driver
could do to become qualified
Certify a driver for an appropriate interval
Indicate certification status, which may require
 waiver / exemption, which the Medical Examiner identifies
 wearing corrective lenses
 wearing a hearing aid
 a Skill Performance Evaluation Certificate
For a driver that is certified with a limited interval, advise them to return for
recertification with the appropriate documentation for his or her condition
Complete a medical examination report and medical certificate/card
 ensure use of currently required examination form
 ensure the form includes the examiner’s name, examination date, office
address, and telephone number
 ensure the driver signs the medical certificate/card
Totals
30 45 25 100
Page 34 of 44
Appendix C: Sample FMCSA Medical Examiner Certification Test Items
Sample Item 1: This item will be testing Detailed Content Outline (DCO) task IB3f (cognitive level:
recall):
3. Examine the driver’s eyes and note
f. reactivity to light and pupillary equality
According to FMCSA regulations, which of the following must the medical examiner evaluate when
examining a driver's eyes?
A.
B.
C.
D.
Pupil reactivity
Iris symmetry
Conjunctival injection
Corneal thickness
Correct Response:
A. Pupil reactivity
This is the correct response because it is the only option that is included on the Medical Examination
Report Form for physical examination of the eyes. This is a cranial nerve test. A positive finding
indicates a significant neurological problem that must be worked up or have an explanation that clarifies
whether or not the driver has a condition that may interfere with the ability to safely operate a CMV.
Incorrect Responses:
B. Iris symmetry
This is incorrect because determining iris symmetry is not required by FMCSA.
C. Conjunctival injection
This is incorrect because most causes of conjunctival injection would not be disqualifying. Causes that
are suspicious for a disqualifying condition need additional evaluation. While this abnormal finding should
be explained, with determination of possible effects on safe driving before making a certification decision,
it is not a condition that is specified in FMCSA regulations.
D. Corneal thickness
This is incorrect because it is not measured in an office examination except by an eye specialist.
Page 35 of 44
Sample Item 2: This item will be testing DCO task IIC6 (cognitive level: recall):
6. Certify a driver for an appropriate interval
According to FMCSA regulations, medical qualification for two years can be given to a driver who has
A.
B.
C.
D.
An SPE certificate for a left below the knee amputation (BKA).
Hypertension.
A recent diagnosis of Lewy body dementia.
Documented medical marijuana use for pain control.
Correct: A. An SPE certificate for a left below the knee amputation.
This is the correct response because in order to obtain the SPE certificate, the driver had to demonstrate
the ability to perform all tasks for the commercial driver job description.
B. Hypertension.
This is not the correct response because drivers with hypertension are only given a medical certificate
that is good for one year.
C. A recent diagnosis of Lewy body dementia.
This is not the correct response because this is a progressive, degenerative condition with no known treatment. The effects of Lewy body dementia impact the ability to operate a CMV safely.
D. Documented medical marijuana use for pain control
This is not the correct response because marijuana remains a drug listed in Schedule I of the Controlled
Substances Act. It remains unacceptable for any safety sensitive employee subject to drug testing under
the drug testing regulations of DOT to use marijuana. Also, FMCSA medical guidelines state that “driving
impairment due to marijuana use is well substantiated.”
Page 36 of 44
Sample Item 3: This item will be testing DCO task IB11e (cognitive level: application):
11. Examine the driver’s extremities and note
e. handgrip and prehension relative to requirements for controlling a
steering wheel and gear shift
During his visit to the medical examiner, a driver complains of severe pain in his finger for the last two
weeks after it was punctured. The examination reveals an infected, swollen finger. After the medical
examiner inquires, the driver states that the pain is made worse when he grips the steering wheel.
Which of the following should the medical examiner do next?
A.
B.
C.
D.
Obtain a hand X-ray.
Assess capillary refill in the hand.
Obtain a culture and sensitivity.
Assess the driver's grip strength.
Correct: D. Assess the driver’s grip strength.
This is the correct response because the condition does not present a safety risk unless it interferes with
the ability of the driver to hold and control the steering wheel.
A. Obtain a hand X-ray.
This is not the correct response because this is a diagnostic test that a healthcare provider or specialist
would perform or order. Your role as a medical examiner is to determine if the condition interferes with
the ability of the driver to safely operate a CMV.
B. Assess capillary refill in the hand.
This is not the correct response because given the information in the question it is not the primary
consideration for determining if the driver can safely operate a CMV.
C. Obtain a culture and sensitivity.
This is not the correct response because this is an action that a treating healthcare provider or specialist
would do in the course workup and treatment. Your role as a medical examiner is to determine if the
condition interferes with the ability of the driver to safely operate a CMV.
Page 37 of 44
Sample Item 4: This item will be testing DCO task IIC8 (cognitive level: application):
8. Advise a driver certified with a limited interval to return for recertification with
the appropriate documentation for his or her condition
A new driver who had a myocardial infarction six months ago is certified after completing an
acceptable exercise tolerance test and is cleared by a cardiologist. According to FMCSA
guidelines, which of the following is recommended regarding recertification and exercise
tolerance test monitoring intervals?
A.
B.
C.
D.
Recertification
Exercise tolerance
Every year
Every two years
Every year
Every two years
Every year
Every year
Every two years
Every two years
Correct: C. every year; every two years
This is the correct response because according to FMCSA medical guidelines, when a myocardial
infarction is part of the medical history, there is a significant increased risk for another myocardial
infarction to occur within six months to a year; therefore, a maximum of one year certification is the
guideline. Myocardial infarction guidelines also recommend exercise tolerance testing at least every two
years to demonstrate continued ability to safely operate a CMV.
A. every year; every year
This is not the correct response because the FMCSA medical guidance is to obtain an exercise tolerance
test every two years. In this question, there is nothing to indicate that more frequent testing is necessary.
B. every two years; every year
This is not the correct response because it reverses the guidelines. Even if you do not recall the
recommendation, logically, one would eliminate this option because having the driver obtain a test every
year and then waiting for up to a year to review the test results is not reasonable when unacceptable test
results indicate the driver may not be able to safely operate a CMV.
D. every two years; every two years
This is not the correct response because the guideline is to recertify every year. Even if you do not recall
the actual guideline, one would logically eliminate this option because this is the maximum recertification
period for a driver who meets all qualification requirements. It is appropriate that a driver at increased risk
for an incapacitating cardiac event should be monitored more frequently.
Page 38 of 44
Sample Item 5: This item will be testing DCO task IA3a (cognitive level: analysis):
3. Identify, query, and note issues in a driver’s medical record and / or health
history as available, which may include
a. specifics regarding any affirmative responses in the history
A 46-year-old male driver presents for recertification. He has a history of chronic gastro esophageal
reflux disease (GERD). He takes esomeprazole (Nexium) and over-the-counter cimetidine
(Tagamet). He states that he feels fine, but has trouble finding foods that do not trigger his GERD
when he is on the road. Which of the following should the medical examiner do first?
A.
B.
C.
D.
Disqualify the driver until he has a nutritional consultation.
Certify the driver and advise him to carry non-triggering foods in a cooler.
Contact the driver's physician and request an upper GI study.
Correlate the GI history findings with the abdominal examination.
Correct: D. Correlate the GI history findings with the abdominal examination.
This is the correct response because given the information in the question; a medical examiner would need to examine the driver before having sufficient information about the health of the driver to consider
any of the other options.
A. Disqualify the driver until he has a nutritional consultation.
This is not the correct response because until completion of the examination, there is insufficient
information to make a certification decision. In addition, there is no regulation or medical guideline that
requires a nutritional consultation in order to be certified.
B. Certify the driver and advise him to carry non-triggering foods in a cooler.
This is not the correct response because until completion of the examination, there is insufficient
information to make a certification decision.
C. Contact the driver’s primary care provider and request an upper-GI study.
This is not the correct response because until completion of the examination, one does not have sufficient
information to make a referral decision.
Page 39 of 44
Sample Item 6: This item will be testing DCO task IIC3 (cognitive level: analysis):
3. Disqualify a driver when evidence shows a condition exists that will likely
interfere with the safe operation of a CMV, which may include sufficient
supporting opinions and information from specialists
A 25-year-old female driver denies a history of any medical problems. She is a nonsmoker who
exercises regularly without symptoms. The medical examiner auscultates bilateral wheezes during
the examination. The driver's SpO2 is 90 percent in the medical examiner's office. The rest of the
examination is normal. The driver should be
A.
B.
C.
D.
Temporarily disqualified pending results of a cardiac workup.
Qualified since she has no cardiac symptoms.
Temporarily disqualified until further evaluation.
Qualified because her O2 saturation exceeds the minimum.
Correct: C. Temporarily disqualified until further evaluation.
This is the correct response because the driver has a non-diagnosed respiratory or thoracic illness that
might interfere with the ability to safely operate a CMV. The driver should not be certified until the
etiology is confirmed and treatment has been shown to be effective, safe, and stable. Also, according to
FMCSA medical guidelines, a SpO2 of less than 92 percent warrants obtaining an arterial blood gas
analysis.
A. Temporarily disqualified pending results of a cardiac workup.
This is not the correct response because while it is correct that the driver should not be certified, there is
nothing in the question data that indicates evaluation should be limited to the heart.
B. Qualified since she has no cardiac symptoms.
This is not the correct response because the information in the question does not provide sufficient data
to rule out the presence of a disqualifying cardiac or other thoracic problem.
D. Qualified because her O2 saturation exceeds the minimum.
This is not the correct response because according to FMCSA guidelines, a SpO2 of less than 92 percent
warrants obtaining an arterial blood gas analysis.
Page 40 of 44
Appendix D: Quick Reference Guide
Federal Motor Carrier Safety Administration (FMCSA) Medical Examiner
Certification and Listing on the National Registry of Certified Medical Examiners
Follow these steps to be an FMCSA certified medical examiner.
Certification
Registration
Step 1: Create Your Account
•
•
•
•
•
•
•
Go to https://nationalregistry.fmcsa.dot.gov to create your National Registry Account.
Select “Registration” option.
Enter required information. (Complete registration or data will not be saved.)
Confirm all information as true and submit entries.
Accept Rules of Behavior and submit.
Receive Welcome Message and National Registry Number.
Receive email with temporary password and instructions.
Training
Step 2: Complete Required Training
•
•
Go to https://nationalregistry.fmcsa.dot.gov to find a list of training providers.
Complete a training program that:
o Is conducted by a training provider that is accredited by a nationally recognized medical
profession accrediting organization to provide continuing education units.
o Provides training participants with proof of participation.
o Provides FMCSA point of contact information to training participants.
o Covers the current core curriculum specifications established by FMCSA for medical
examiner training.
Certification Testing
Step 3: Take the FMCSA Medical Examiner Certification Test
•
•
•
•
•
Go to https://nationalregistry.fmcsa.dot.gov to search for a list of testing organizations approved
to administer the FMCSA Medical Examiner Certification Test.
Obtain information about locations and scheduling instructions directly from the testing organizations.
Schedule the test. Some testing organizations may provide an option to take the test using a
secure, remote, computer-based system.
Provide your National Registry Number, proof of current medical licensure, proof of completion of
training, and one form of photo identification when arriving at the test center.
Take and pass the FMCSA Medical Examiner Certification Test.
Page 41 of 44
Recertification (required every 10 years)
Training
Step 1: Complete Periodic Training
• Complete periodic training as specified by FMCSA every 5 years.
• Go to https://nationalregistry.fmcsa.dot.gov for information about how to access and complete
periodic training.
Certification Testing
Step 2: Take the FMCSA Medical Examiner Certification Test
• Go to https://nationalregistry.fmcsa.dot.gov to:
o Apply for recertification.
o Accept Rules of Behavior and submit.
o Find links to testing organizations approved to administer the FMCSA Medical Examiner
Certification Test.
• Obtain information about locations and scheduling instructions directly from the testing organizations.
• Schedule the test.
• Provide your National Registry Number, proof of your medical credential, proof of completion of
training, and one form of photo identification when arriving at the test center to take the test.
• Take and pass the FMCSA Medical Examiner Certification Test.
Continued Listing on the National Registry
To continue listing on the National Registry of Certified Medical Examiners, you must comply with the
following requirements.
General Requirements
• Report to FMCSA any changes in the application information within 30 days of the change.
• Continue to be licensed, certified, or registered, and authorized to perform physical examinations,
in accordance with the applicable laws and regulations of each State in which you perform driver
examinations.
• Maintain documentation of State licensure, registration, or certification to perform physical
examinations for each State in which you perform examinations and documentation of completion
of all required training. You must make this documentation available to an authorized
representative of FMCSA or an authorized representative of Federal, State, or local government
upon request.
Periodic Training
• Complete periodic training as specified by FMCSA every 5 years.
Recertification
• Complete recertification by taking and passing the FMCSA Medical Examiner Certification Test
every 10 years. (Note: FMCSA will issue a new medical examiner certification credential valid
for 10 years when you successfully complete the required training and testing).
Submission of Monthly Reports/Commercial Motor Vehicle Driver Medical Examination Results
• Once every calendar month, you must electronically transmit to the Director of Medical Programs,
via a secure FMCSA-designated Website, a completed Form MCSA-5850, Medical Examiner
Submission of CMV Driver Medical Examination Results.
• The Form must include all information specified for each medical examination conducted during
the previous month for any driver who is required to be examined by a medical examiner listed on
the National Registry of Certified Medical Examiners.
Page 42 of 44
Appendix E: FMCSA Form MCSA-5850, CMV Driver Medical Examination Results
CMV Driver Medical Examination Results Form
U.S. Department of Transportation
OMB Control Number: 2126-0006
Expiration Date: July 31, 2015
Assigned FMCSA Form Number: MCSA-5850
Public Burden Statement:
A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a
penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that
collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is
2126-0006. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the
time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses
to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection
of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier
Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.
You are required to submit the following driver medical examination data every month.
Complete this form for each driver medical examination concluded.
Page 43 of 44
National Registry of Certified Medical Examiners Privacy Act Statement
This statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The information on the attached Form
MCSA-5850 CMV Driver Examination Results is solicited under the authority of Title 49, United States Code (U.S.C.)
§§ 40113, 44702, 44703, 44709 and 14 C.F.R. Part 6-7.
With limited exceptions, all drivers who operate commercial motor vehicles (CMVs), as defined in 49 CFR 390.5, in
interstate commerce must comply with the qualification requirements of part 391 (§ 391.1). Each driver subject to the
physical qualification requirements must be examined and certified by a medical examiner, as defined in § 390.5, at
least once every 2 years. For certain drivers, such as those with severe cases of hypertension or other acute medical
conditions, more frequent medical re-examination by a medical examiner may be required to determine whether the
driver can still be certified.
Medical examiners are required to submit data every month for each driver physical examination conducted. Driver or
medical examiner social security number is not required. Incomplete submission may result in removal of a medical
examiner from the National Registry Program. The purpose of information is to record results of a driver’s physical
qualification to operate a CMV in interstate commerce according to the requirement in 49 CFR 391.41-49.
The information will be used to provide data for FMCSA’s automated National Registry Data System. The information
will become part of an FMCSA Privacy Act system of record. These records and information in these records will be
collected and used to link a specific medical examiner to specific driver medical examination outcome data.
The written consent authorization of this form under OMB Control Number: 2126-0006 permits FMCSA to request
driver physical examination outcome data from medical examiners.
Page 44 of 44
Medical Examination Report
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
649-F (6045)
1. DRIVER'S INFORMATION
Driver completes this section
Driver's Name (Last, First, Middle)
Social Security No.
Birthdate
M/D/Y
Address
City, State, Zip Code
Work Tel: ( )
Age
New Certification
Sex
M Recertification
F Follow-up
Driver License No. License Class
A
B
Home Tel: ( )
2. HEALTH HISTORY
Date of Exam
State of Issue
C
D
Other
Driver completes this section, but medical examiner is encouraged to discuss with driver.
Yes No
Yes No
Yes No
Any illness or injury in the 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
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____________________
Fainting, dizziness
Sleep disorders, pauses in breathing
while asleep, daytime sleepiness, loud
snoring
Loss of, or altered consciousness
Regular, frequent alcohol use
Narcotic or habit forming drug use
Stroke or paralysis
Missing or impaired hand, arm, foot, leg,
finger, toe
Spinal injury or disease
Chronic low back pain
For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including
over-the-counter medications) used regularly or recently.
I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my
Medical Examiner's Certificate.
Driver's Signature
Date
Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of
medications, including over-the-counter medications, while driving. This discussion must be documented below. )
179
TESTING (Medical Examiner completes Section 3 through 7) Name:
3.
Last,
First,
Middle,
Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian
measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.
VISION
INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a
ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver
habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.
Numerical readings must be provided.
ACUITY
UNCORRECTED
CORRECTED
Right Eye
20/
20/
Right Eye
Left Eye
20/
20/
Left Eye
Both Eyes
20/
20/
HORIZONTAL FIELD OF VISION
Applicant can recognize and distinguish among traffic control
sign als and devices showing standard red, green, and amber colors ?
Yes
No
Applicant meets visual acuity requirement only when wearing:
Corrective Lenses
Monocular Vision:
Yes
No
Complete next line only if vision testing is done by an opthalmologist or optometrist
Date of Examination
4.
HEARING
Name of Ophthalmologist or Optometrist (print)
Tel. No.
License No./ State of Issue
Signature
Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB
Check if hearing aid used for tests.
Check if hearing aid required to meet standard.
INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3
frequencies tested and divide by 3.
Numerical readings must be recorded.
a) Record distance from individual at which
forced whispered voice can first be heard.
5. BLOOD PRESSURE/ PULSE RATE
Blood
Pressure
Systolic
Diastolic
Right Ear
Right ear
Left Ear
\ Feet
\ Feet
b) If audiometer is used, record hearing loss in
decibels. (acc. to ANSI Z24.5-1951)
500 Hz
Regular
Irregular
1000 Hz
Average:
2000 Hz 500 Hz
1000 Hz 2000 Hz
Average:
Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.
Reading
140-159/90-99
Category
Stage 1
Expiration Date
1 year
160-179/100-109
Stage 2
One-time certificate for 3 months.
Recertification
1 year if <140/90.
One-time certificate for 3 months if
141-159/91-99.
1 year from date of exam if <140/90
>180/110
Stage 3
6 months from date of exam if <140/90
6 months if < 140/90
Driver qualified if <140/90.
Pulse Rate: Left Ear
6. LABORATORY AND OTHER TEST FINDINGS
SP. GR.
PROTEIN
BLOOD SUGAR
URINE SPECIMEN
Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Other Testing (Describe and record)
180
7
7.
PHYSICAL EXAMINATION
Height:
(in.) Weight:
Name:
(lbs.)
Last,
First,
Middle,
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment.
Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct
the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.
Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's
ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for.
See Instructions to the Medical Examiner for guidance.
BODY SYSTEM
1. General Appearance
2. Eyes
CHECK FOR:
YES* NO
Marked overweight, tremor, signs of alcoholism, problem
drinking, or drug abuse.
7. Abdomen and Viscera
Pupillary equality, reaction to light, accommodation, ocular
motility, ocular muscle imbalance, extraocular movement,
nystagmus, exophthalmos. Ask about retinopathy, cataracts,
aphakia, glaucoma, macular degeneration and refer to a
specialist if appropriate.
3. Ears
8. Vascular System
Scarring of tympanic membrane, occlusion of external canal,
perforated eardrums.
4. Mouth and Throat
Irremediable deformities likely to interfere with breathing or
swallowing.
5. Heart
Murmurs, extra sounds, enlarged heart, pacemaker,
implantable defibrillator.
6. Lungs and chest,
not including breast
examination
BODY SYSTEM
Abnormal chest wall expansion, abnormal respiratory rate,
abnormal breath sounds including wheezes or alveolar rales,
impaired respiratory function, cyanosis. Abnormal findings on
physical exam may require further testing such as pulmonary
tests and/ or xray of chest.
YES* NO
CHECK FOR:
Enlarged liver, enlarged spleen, masses, bruits,
hernia, significant abdominal wall muscle
weakness.
Abnormal pulse and amplitude, cartoid or
arterial bruits, varicose veins.
9. Genito-urinary System
Hernias.
10. Extremities- Limb
impaired. Driver may
be subject to SPE
certificate if otherwise
qualified.
Loss or impairment of leg, foot, toe, arm, hand,
finger, Perceptible limp, deformities, atrophy,
weakness, paralysis, clubbing, edema,
hypotonia. Insufficicent grasp and prehension
in upper limb to maintain steering wheel grip.
Insufficient mobility and strength in lower limb
to operate pedals properly.
11. Spine, other
musculoskeletal
Previous surgery, deformities, limitation of
motion, tenderness.
12. Neurological
Impaired equilibrium, coordination or speech
pattern; asymmetric deep tendon reflexes,
sensory or positional abnormalities, abnormal
patellar and Babinki's reflexes, ataxia.
*COMMENTS:
Note certification status here. See Instructions to the Medical Examiner for guidance.
Meets standards in 49 CFR 391.41; qualifies for 2 year certificate
Does not meet standards
Meets standards, but periodic monitoring required due to
Driver qualified only for: 3 months
6 months
1 year
Other
Temporarily disqualified due to (condition or medication):
Return to medical examiner's office for follow up on
.
Wearing corrective lense
Wearing hearing aid
Accompanied by a
waiver/ exemption. Driver must present
exemption at time of certification.
Skill Performanc e Evaluation (SPE) Certificate
Driving within an exempt intracity zone (See 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64
Medical Examiner's signature
Medical Examiner's name Address
Telephone Number If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h). (Driver must carry certificate when operating a commercial vehicle.)
181
49 CFR 391.41 Physical Qualifications for Drivers
THE DRIVER'S ROLE
Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main
types of drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at
least a 10-hour off-duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and
5-hour rest periods.)
The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep
patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight
pickup and delivery schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to
hurriedly loading or unloading cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in
temperature. Transporting passengers or hazardous materials may add to the demands on the commercial driver.
There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling
trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long
period of time without any stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and
removing heavy tire chains; and, lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a
crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s).
In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary,
and the manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.
§391.45 PHYSICAL QUALIFICATIONS FOR DRIVERS
(a) A person shall not drive a commercial motor vehicle unless he
is physically qualified to do so and, except as provided in §391.67,
has on his person the original, or a photographic copy, of a medical
examiner's certificate that he is physically qualified to drive a
commercial motor vehicle.
(b) A person is physically qualified 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) Certificate (formerly
Limb Waiver Program) pursuant to §391.49.
(2) Has no impairment of: (i) A hand or finger 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 significant 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 Certificate 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 clinical
diagnosis of rheumatic, arthritic, orthopedic, muscular,
neuromuscular, or vascular disease which interferes with his
ability to control and operate a commercial motor vehicle safely.
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,
distant binocular acuity of at least 20/40 (Snellen) in both eyes
with or without corrective lenses, field 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 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 device when the audiometric device is calibrated to the
American National Standard (formerly ASA Standard)
Z24.5-1951;
(12) (i) Does not use a controlled
substance identified in 21 CFR 1308.11 Schedule
I, an amphetamine, a narcotic, or any other
habit-forming drug. (ii) Exception: A driver may
use such a substance or drug, 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; and
(13) Has no current clinical diagnosis of
alcoholism.
182
INSTRUCTIONS TO THE MEDICAL EXAMINER
General Information
The purpose of this examination is to determine a driver's physical
qualification to operate a commercial motor vehicle (CMV) in interstate
commerce according to the requirements in 49 CFR 391.41-49. Therefore,
the medical examiner must be knowledgeable of these requirements and
guidelines developed by the FMCSA to assist the medical examiner in
making the qualification determination. The medical examiner should be
familiar with the driver's responsibilities and work environment and is
referred to the section on the form, The Driver's Role.
In addition to reviewing the Health History section with the driver and
conducting the physical examination, the medical examiner should discuss
common prescriptions and over-the-counter medications relative to the side
effects and hazards of these medications while driving. Educate the driver
to read warning labels on all medications. History of certain conditions may
be cause for rejection, particularly if required by regulation, or may indicate
the need for additional laboratory tests or more stringent examination
perhaps by a medical specialist. These decisions are usually made by the
medical examiner in light of the driver's job responsibilities, work schedule
and potential for the conditions to render the driver unsafe.
Medical conditions should be recorded even if they are not cause for
denial, and they should be discussed with the driver to encourage
appropriate remedial care. This advice is especially needed when a
condition, if neglected, could develop into a serious illness that could affect
driving.
If the medical examiner determines that the driver is fit to drive and is
also able to perform non-driving responsibilities as may be required, the
medical examiner signs the medical certificate which the driver must carry
with his/her license. The certificate must be dated. Under current
regulations, the certificate is valid for two years, unless the driver has
a medical condition that does not prohibit driving but does require
more frequent monitoring. In such situations, the medical certificate
should be issued for a shorter length of time. The physical examination
should be done carefully and at least as complete as is indicated by the
attached form. Contact the FMCSA at (202) 366-1790 for further
information (a vision exemption, qualifying drivers under 49 CFR 391.64,
etc.).
Interpretation of Medical Standards
Since the issuance of the regulations for physical qualifications of
commercial drivers, the Federal Motor Carrier Safety Administration
(FMCSA) has published recommendations called Advisory Criteria to help
medical examiners in determining whether a driver meets the physical
qualifications for commercial driving. These recommendations have been
condensed to provide information to medical examiners that (1) is directly
relevant to the physical examination and (2) is not already included in the
medical examination form. The specific regulation is printed in italics and
it's reference by section is highlighted.
Federal Motor Carrier Safety Regulations
-Advisory CriteriaLoss 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) Certificate
pursuant to Section 391.49.
Limb Impairment:
§391.41(b)(2)
Has no impairment of: (i) A hand or finger 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 (iii)
Any other significant limb defect or limitation which interferes
with the ability to perform normal tasks associated with
operating a commercial motor vehicle; or (iv) Has been
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 Certification Program pursuant to section
391.49, assuming the person is otherwise qualified.
With the advancement of technology, medical aids and
equipment modifications have been developed to compensate
for certain disabilities. The SPE Certification Program
(formerly the Limb 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 modifications 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 certificates 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 qualified
(391.41(b)(3) through (13)), the medical examiner must check
on the medical certificate that the driver is qualified only if
accompanied by a SPE certificate. The driver and the employing
motor carrier are subject to appropriate penalty if the driver
operates a motor vehicle in interstate or foreign commerce
without a curent SPE certificate for his/her physical disability.
Diabetes
§391.41(b)(3)
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, semiconsciousness, 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 qualified under the present rule. CMV
drivers who do not meet the Federal diabetes standard
may call (202) 366-1790 for an application for a diabetes
exemption.
(See Conference Report on Diabetic Disorders and
Commercial Drivers and Insulin-Using Commercial Motor
Vehicle Drivers at:
http://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
specifically 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
184 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
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 qualification 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 certified 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 condition(s) which require treatment and
the general health of the driver. The FMCSA should be
contacted at (202) 366-1790 for additional
recommendations regarding the physical qualification of
drivers on coumadin.
(See Cardiovasular Advisory Panel Guidelines for the
Medical examination of Commercial Motor Vehicle Drivers
at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)
Respiratory Dysfunction
§391.41(b)(5)
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.
Hypertension
§391.41(b)(6)
Has no current clinical diagnosis of high blood pressure
likely to interfere with 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 certified to drive for a one-year period. Certification examinations should be done annually
thereafter and should be at or less than 140/90. If less than
160/100, certification may be extended one time for 3
months.
A blood 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
certification 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 certified for one year from date of the initial exam.
The driver is certified 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 not be qualified, even
temporarily, until reduced to 140/90 or less and treatment is
well tolerated. The driver may be certified for 6 months and
biannually (every 6 months) thereafter if at recheck BP is
140/90 or less. Annual recertification is recommended if the medical
examiner does not know the severity of hypertension prior
to treatment.
An elevated blood pressure finding 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 particulary undesirable in
commercial drivers.
Secondary hypertension is based on the above stages.
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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 qualified: (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 certification 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 qualified.
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
not taking antiseizure medication.
Drivers with a history of epilepsy/seizures off antiseizure
medication and seizure-free for 10 years may be qualified to drive
a CMV in interstate commerce. Interstate drivers with a history of
a single unprovoked seizure may be qualified 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:
Mental Disorders
§391.41(b)(9)
Has no mental, nervous, organic or functional disease or
psychiatric disorder likely to interfere with 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 certification for commercial driving is inadvisable. Somatic
and psychosomatic complaints should be thoroughly examined
when determining an individual's overall fitness to drive.
Disorders of a periodically incapacitating nature, even in the
early stages of development, may warrant disqualification.
Many bus and truck drivers have documented that "nervous
trouble" related to neurotic, personality, or emotional or
adjustment problems is responsible for a significant 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 flexibility 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
disqualification. Careful consideration should be given to the
side effects and interactions of medications in the overall
qualification determination. See Psychiatric Conference Report
for specific recommendations on the use of medications and
potential hazards for driving.
(See Conference on Psychiatric Disorders and Commercial
Drivers at:
Vision
§391.41(b)(10)
Has distant visual acuity of at least 20/40 (Snellen) in each eye
with or without corrective lenses or visual acuity separately
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 deficiency. If
certain color perception tests are administered, (such as
Ishihara, Pseudoisochromatic, Yarn) and doubtful findings 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 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 Certificate: "Qualified only if wearing
corrective lenses."
CMV drivers who do not meet the Federal vision standard
may call (202) 366-1790 for an application for a vision
exemption.
(See Visual Disorders and Commercial Drivers at:
Hearing
§391.41(b)(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 to American National
Standard (formerly ADA Standard) Z24.5-1951.
Since the prescribed standard under the FMCSRs is the
American Standards Association (ANSI), it may be necessary to
convert the audiometric 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 186
expiration, the
examiner whispers words or random numbers such as 66, 18,
23, etc. The examiner should not use only sibilants (s sounding
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 Certificate
"Qualified only when wearing a hearing aid."
(See Hearing Disorders and Commercial Motor Vehicle Drivers at:
http://www/fmcsa.dot.gov/rulesregs/medrports.htm)
Drug Use
§391.41(b)(12)
A person is physically qualified to drive a commercial motor vehicle if that
person:
Does not use a controlled substance identified in 21 CFR 1308.II.
Schedule I, an amphetamine, a narcotic, or any other habit-forming drug.
Exception: A driver may use such a substance or drug, if the substance or
drug is prescribed by a licensed medical practitioner who is familiar with
the driver's medical history and assigned duties; and 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
certification 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 unqualified.
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 fluid testing. If body fluid testing takes place,
positive test results should be confirmed by a second test of greater
specificity. 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 unqualified 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. Recertification may involve a substance abuse
evaluation, the successful completion of a drug rehabilitation program, and
a negative drug test result. Additionally, given that the certification 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:
Alcoholism
§391.41(b)(13)
person:
Has no current clinical diagnosis of alcoholism.
The term "current clinical diagnosis of" is specifically 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
186
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189189
MEDICAL EXAMINER’S CERTIFICATE
I certify that I have examined _____________________________________________________________ in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when:
 wearing corrective lenses
 wearing hearing aid
 accompanied by a______________________ waiver/exemption
 driving within an exempt intracity zone (49 CFR 391.62)
 accompanied by a Skill Performance Evaluation Certificate (SPE)
 qualified by operation of 49 CFR 391.64
The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my
findings completely and correctly, and is on file in my office.
SIGNATURE OF MEDICAL EXAMINER
TELEPHONE
DATE
MEDICAL EXAMINER’S NAME (PRINT)
 MD
 DO
 Physician Assistant
MEDICAL EXAMINER’S LICENSE OR
CERTIFICATE NO./ISSUING STATE
NATIONAL REGISTRY NO.
SIGNATURE OF DRIVER
INTRASTATE ONLY
CDL
 YES
 NO
 YES
 NO
 Chiropractor
 Advanced Practice Nurse
 Other Practitioner
DRIVER’S LICENSE NO.
STATE
ADDRESS OF DRIVER
MEDICAL CERTIFICATION EXPIRATION DATE
188
Medical Examination Report
FOR COMMERCIAL DRIVER FITNESS DETERMINATION
649-F (6045)
1. DRIVER'S INFORMATION
Driver completes this section
Driver's Name (Last, First, Middle)
Social Security No.
Birthdate
M/D/Y
Address
City, State, Zip Code
Work Tel: ( )
Age
New Certification
Sex
M Recertification
F Follow-up
Driver License No. License Class
A
B
Home Tel: ( )
2. HEALTH HISTORY
Date of Exam
State of Issue
C
D
Other
Driver completes this section, but medical examiner is encouraged to discuss with driver.
Yes No
Yes No
Yes No
Any illness or injury in the 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
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____________________
Fainting, dizziness
Sleep disorders, pauses in breathing
while asleep, daytime sleepiness, loud
snoring
Loss of, or altered consciousness
Regular, frequent alcohol use
Narcotic or habit forming drug use
Stroke or paralysis
Missing or impaired hand, arm, foot, leg,
finger, toe
Spinal injury or disease
Chronic low back pain
For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including
over-the-counter medications) used regularly or recently.
I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my
Medical Examiner's Certificate.
Driver's Signature
Date
Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of
medications, including over-the-counter medications, while driving. This discussion must be documented below. )
179
TESTING (Medical Examiner completes Section 3 through 7) Name:
3.
Last,
First,
Middle,
Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian
measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.
VISION
INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a
ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver
habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.
Numerical readings must be provided.
ACUITY
UNCORRECTED
CORRECTED
Right Eye
20/
20/
Right Eye
Left Eye
20/
20/
Left Eye
Both Eyes
20/
20/
HORIZONTAL FIELD OF VISION
Applicant can recognize and distinguish among traffic control
sign als and devices showing standard red, green, and amber colors ?
Yes
No
Applicant meets visual acuity requirement only when wearing:
Corrective Lenses
Monocular Vision:
Yes
No
Complete next line only if vision testing is done by an opthalmologist or optometrist
Date of Examination
4.
HEARING
Name of Ophthalmologist or Optometrist (print)
Tel. No.
License No./ State of Issue
Signature
Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB
Check if hearing aid used for tests.
Check if hearing aid required to meet standard.
INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3
frequencies tested and divide by 3.
a) Record distance from individual at which
forced whispered voice can first be heard.
5. BLOOD PRESSURE/ PULSE RATE
Blood
Pressure
Systolic
Diastolic
Right Ear
Right ear
Left Ear
\ Feet
\ Feet
b) If audiometer is used, record hearing loss in
decibels. (acc. to ANSI Z24.5-1951)
500 Hz
Regular
Irregular
1000 Hz
Average:
2000 Hz 500 Hz
1000 Hz 2000 Hz
Average:
Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.
Reading
140-159/90-99
Category
Stage 1
Expiration Date
1 year
160-179/100-109
Stage 2
One-time certificate for 3 months.
Recertification
1 year if <140/90.
One-time certificate for 3 months if
141-159/91-99.
1 year from date of exam if <140/90
>180/110
Stage 3
6 months from date of exam if <140/90
6 months if < 140/90
Driver qualified if <140/90.
Pulse Rate: Left Ear
6. LABORATORY AND OTHER TEST FINDINGS
SP. GR.
PROTEIN
BLOOD SUGAR
URINE SPECIMEN
Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to
rule out any underlying medical problem.
Other Testing (Describe and record)
180
7
7.
PHYSICAL EXAMINATION
Height:
(in.) Weight:
Name:
(lbs.)
Last,
First,
Middle,
The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment.
Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct
the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.
Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's
ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for.
See Instructions to the Medical Examiner for guidance.
BODY SYSTEM
1. General Appearance
2. Eyes
CHECK FOR:
YES* NO
Marked overweight, tremor, signs of alcoholism, problem
drinking, or drug abuse.
7. Abdomen and Viscera
Pupillary equality, reaction to light, accommodation, ocular
motility, ocular muscle imbalance, extraocular movement,
nystagmus, exophthalmos. Ask about retinopathy, cataracts,
aphakia, glaucoma, macular degeneration and refer to a
specialist if appropriate.
3. Ears
8. Vascular System
Scarring of tympanic membrane, occlusion of external canal,
perforated eardrums.
4. Mouth and Throat
Irremediable deformities likely to interfere with breathing or
swallowing.
5. Heart
Murmurs, extra sounds, enlarged heart, pacemaker,
implantable defibrillator.
6. Lungs and chest,
not including breast
examination
BODY SYSTEM
Abnormal chest wall expansion, abnormal respiratory rate,
abnormal breath sounds including wheezes or alveolar rales,
impaired respiratory function, cyanosis. Abnormal findings on
physical exam may require further testing such as pulmonary
tests and/ or xray of chest.
YES* NO
CHECK FOR:
Enlarged liver, enlarged spleen, masses, bruits,
hernia, significant abdominal wall muscle
weakness.
Abnormal pulse and amplitude, cartoid or
arterial bruits, varicose veins.
9. Genito-urinary System
Hernias.
10. Extremities- Limb
impaired. Driver may
be subject to SPE
certificate if otherwise
qualified.
Loss or impairment of leg, foot, toe, arm, hand,
finger, Perceptible limp, deformities, atrophy,
weakness, paralysis, clubbing, edema,
hypotonia. Insufficicent grasp and prehension
in upper limb to maintain steering wheel grip.
Insufficient mobility and strength in lower limb
to operate pedals properly.
11. Spine, other
musculoskeletal
Previous surgery, deformities, limitation of
motion, tenderness.
12. Neurological
Impaired equilibrium, coordination or speech
pattern; asymmetric deep tendon reflexes,
sensory or positional abnormalities, abnormal
patellar and Babinki's reflexes, ataxia.
*COMMENTS:
Note certification status here. See Instructions to the Medical Examiner for guidance.
Meets standards in 49 CFR 391.41; qualifies for 2 year certificate
Does not meet standards
Meets standards, but periodic monitoring required due to
Driver qualified only for: 3 months
6 months
1 year
Other
Temporarily disqualified due to (condition or medication):
Return to medical examiner's office for follow up on
.
Wearing corrective lense
Wearing hearing aid
Accompanied by a
waiver/ exemption. Driver must present
exemption at time of certification.
Skill Performanc e Evaluation (SPE) Certificate
Driving within an exempt intracity zone (See 49 CFR 391.62)
Qualified by operation of 49 CFR 391.64
Medical Examiner's signature
Medical Examiner's name Address
Telephone Number If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h). (Driver must carry certificate when operating a commercial vehicle.)
181
49 CFR 391.41 Physical Qualifications for Drivers
THE DRIVER'S ROLE
Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main
types of drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at
least a 10-hour off-duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and
5-hour rest periods.)
The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep
patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight
pickup and delivery schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to
hurriedly loading or unloading cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in
temperature. Transporting passengers or hazardous materials may add to the demands on the commercial driver.
There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling
trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long
period of time without any stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and
removing heavy tire chains; and, lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a
crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s).
In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary,
and the manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.
§391.45 PHYSICAL QUALIFICATIONS FOR DRIVERS
(a) A person shall not drive a commercial motor vehicle unless he
is physically qualified to do so and, except as provided in §391.67,
has on his person the original, or a photographic copy, of a medical
examiner's certificate that he is physically qualified to drive a
commercial motor vehicle.
(b) A person is physically qualified 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) Certificate (formerly
Limb Waiver Program) pursuant to §391.49.
(2) Has no impairment of: (i) A hand or finger 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 significant 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 Certificate 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
(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.
diagnosis of rheumatic, arthritic, orthopedic, muscular,
neuromuscular, or vascular disease which interferes with his
ability to control and operate a commercial motor vehicle safely.
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
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 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 device when the audiometric device is calibrated to the
American National Standard (formerly ASA Standard)
Z24.5-1951;
(12) (i) Does not use a controlled
substance identified in 21 CFR 1308.11 Schedule
I, an amphetamine, a narcotic, or any other
habit-forming drug. (ii) Exception: A driver may
use such a substance or drug, 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; and
(13) Has no current clinical diagnosis of
alcoholism.
182
INSTRUCTIONS TO THE MEDICAL EXAMINER
General Information
The purpose of this examination is to determine a driver's physical
qualification to operate a commercial motor vehicle (CMV) in interstate
commerce according to the requirements in 49 CFR 391.41-49. Therefore,
the medical examiner must be knowledgeable of these requirements and
guidelines developed by the FMCSA to assist the medical examiner in
making the qualification determination. The medical examiner should be
familiar with the driver's responsibilities and work environment and is
referred to the section on the form, The Driver's Role.
In addition to reviewing the Health History section with the driver and
conducting the physical examination, the medical examiner should discuss
common prescriptions and over-the-counter medications relative to the side
effects and hazards of these medications while driving. Educate the driver
to read warning labels on all medications. History of certain conditions may
be cause for rejection, particularly if required by regulation, or may indicate
the need for additional laboratory tests or more stringent examination
perhaps by a medical specialist. These decisions are usually made by the
medical examiner in light of the driver's job responsibilities, work schedule
and potential for the conditions to render the driver unsafe.
Medical conditions should be recorded even if they are not cause for
denial, and they should be discussed with the driver to encourage
appropriate remedial care. This advice is especially needed when a
condition, if neglected, could develop into a serious illness that could affect
driving.
If the medical examiner determines that the driver is fit to drive and is
also able to perform non-driving responsibilities as may be required, the
medical examiner signs the medical certificate which the driver must carry
with his/her license. The certificate must be dated. Under current
regulations, the certificate is valid for two years, unless the driver has
a medical condition that does not prohibit driving but does require
more frequent monitoring. In such situations, the medical certificate
should be issued for a shorter length of time. The physical examination
should be done carefully and at least as complete as is indicated by the
attached form. Contact the FMCSA at (202) 366-1790 for further
information (a vision exemption, qualifying drivers under 49 CFR 391.64,
etc.).
Interpretation of Medical Standards
Since the issuance of the regulations for physical qualifications of
commercial drivers, the Federal Motor Carrier Safety Administration
(FMCSA) has published recommendations called Advisory Criteria to help
medical examiners in determining whether a driver meets the physical
qualifications for commercial driving. These recommendations have been
condensed to provide information to medical examiners that (1) is directly
relevant to the physical examination and (2) is not already included in the
medical examination form. The specific regulation is printed in italics and
it's reference by section is highlighted.
Federal Motor Carrier Safety Regulations
-Advisory CriteriaLoss of Limb:
§391.41(b)(1)
Has no loss of a foot, leg, hand or an arm, or has been
Limb Impairment:
§391.41(b)(2)
Has no impairment of: (i) A hand or finger 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 (iii)
Any other significant limb defect or limitation which interferes
with the ability to perform normal tasks associated with
operating a commercial motor vehicle; or (iv) Has been
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 Certification Program pursuant to section
391.49, assuming the person is otherwise qualified.
With the advancement of technology, medical aids and
equipment modifications have been developed to compensate
for certain disabilities. The SPE Certification Program
(formerly the Limb 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 modifications 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 certificates 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 qualified
(391.41(b)(3) through (13)), the medical examiner must check
on the medical certificate that the driver is qualified only if
accompanied by a SPE certificate. The driver and the employing
motor carrier are subject to appropriate penalty if the driver
operates a motor vehicle in interstate or foreign commerce
without a curent SPE certificate for his/her physical disability.
Diabetes
§391.41(b)(3)
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, semiconsciousness, 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 qualified under the present rule. CMV
drivers who do not meet the Federal diabetes standard
may call (202) 366-1790 for an application for a diabetes
exemption.
(See Conference Report on Diabetic Disorders and
Commercial Drivers and Insulin-Using Commercial Motor
Vehicle Drivers at:
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
specifically 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
184 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
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 qualification 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 certified 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 condition(s) which require treatment and
the general health of the driver. The FMCSA should be
contacted at (202) 366-1790 for additional
recommendations regarding the physical qualification of
drivers on coumadin.
(See Cardiovasular Advisory Panel Guidelines for the
Medical examination of Commercial Motor Vehicle Drivers
at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)
Respiratory Dysfunction
§391.41(b)(5)
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
and Commercial Drivers at:
http://www.fmcsa.dot.gov/rulesregs/medreports.htm
Hypertension
§391.41(b)(6)
Has no current clinical diagnosis of high blood pressure
likely to interfere with 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 certified to drive for a one-year period. Certification examinations should be done annually
thereafter and should be at or less than 140/90. If less than
160/100, certification may be extended one time for 3
months.
A blood 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
certification 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 certified for one year from date of the initial exam.
The driver is certified 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 not be qualified, even
temporarily, until reduced to 140/90 or less and treatment is
well tolerated. The driver may be certified for 6 months and
biannually (every 6 months) thereafter if at recheck BP is
140/90 or less. Annual recertification is recommended if the medical
examiner does not know the severity of hypertension prior
to treatment.
An elevated blood pressure finding 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 particulary undesirable in
commercial drivers.
Secondary hypertension is based on the above stages.
Evaluation is warranted if patient is persistently hypertensive
on maximal or near-maximal doses of 2-3 pharmacologic agents.
Some causes of secondary hypertension may be amenable to surgical
intervention or specific pharmacologic disease.
(See Cardiovascular Advisory Panel Guidelines for the Medical
Examination of Commercial Motor Vehicle Drivers at:
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 certificate for a shorter period of time may be issued. (See
Conference on Neurological Disorders and Commercial Drivers at:
184
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 qualified: (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 certification 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 qualified.
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
not taking antiseizure medication.
Drivers with a history of epilepsy/seizures off antiseizure
medication and seizure-free for 10 years may be qualified to drive
a CMV in interstate commerce. Interstate drivers with a history of
a single unprovoked seizure may be qualified 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:
Mental Disorders
§391.41(b)(9)
Has no mental, nervous, organic or functional disease or
psychiatric disorder likely to interfere with 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 certification for commercial driving is inadvisable. Somatic
and psychosomatic complaints should be thoroughly examined
when determining an individual's overall fitness to drive.
Disorders of a periodically incapacitating nature, even in the
early stages of development, may warrant disqualification.
Many bus and truck drivers have documented that "nervous
trouble" related to neurotic, personality, or emotional or
adjustment problems is responsible for a significant 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 flexibility 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
disqualification. Careful consideration should be given to the
side effects and interactions of medications in the overall
qualification determination. See Psychiatric Conference Report
for specific recommendations on the use of medications and
potential hazards for driving.
(See Conference on Psychiatric Disorders and Commercial
Drivers at:
Vision
§391.41(b)(10)
Has distant visual acuity of at least 20/40 (Snellen) in each eye
with or without corrective lenses or visual acuity separately
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 deficiency. If
certain color perception tests are administered, (such as
Ishihara, Pseudoisochromatic, Yarn) and doubtful findings 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 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 Certificate: "Qualified only if wearing
corrective lenses."
CMV drivers who do not meet the Federal vision standard
may call (202) 366-1790 for an application for a vision
exemption.
(See Visual Disorders and Commercial Drivers at:
Hearing
§391.41(b)(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 to American National
Standard (formerly ADA Standard) Z24.5-1951.
Since the prescribed standard under the FMCSRs is the
American Standards Association (ANSI), it may be necessary to
convert the audiometric 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 186
expiration, the
examiner whispers words or random numbers such as 66, 18,
23, etc. The examiner should not use only sibilants (s sounding
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 Certificate
"Qualified only when wearing a hearing aid."
(See Hearing Disorders and Commercial Motor Vehicle Drivers at:
http://www/fmcsa.dot.gov/rulesregs/medrports.htm)
Drug Use
§391.41(b)(12)
person:
Does not use a controlled substance identified in 21 CFR 1308.II.
Schedule I, an amphetamine, a narcotic, or any other habit-forming drug.
Exception: A driver may use such a substance or drug, if the substance or
drug is prescribed by a licensed medical practitioner who is familiar with
the driver's medical history and assigned duties; and 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
certification 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 unqualified.
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 fluid testing. If body fluid testing takes place,
positive test results should be confirmed by a second test of greater
specificity. 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 unqualified 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. Recertification may involve a substance abuse
evaluation, the successful completion of a drug rehabilitation program, and
a negative drug test result. Additionally, given that the certification 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:
Alcoholism
§391.41(b)(13)
person:
Has no current clinical diagnosis of alcoholism.
The term "current clinical diagnosis of" is specifically 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 certification.
186
187
189189
MEDICAL EXAMINER’S CERTIFICATE
I certify that I have examined _____________________________________________________________ in accordance with the Federal Motor Carrier Safety
Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when:
 wearing corrective lenses
 wearing hearing aid
 accompanied by a______________________ waiver/exemption
 driving within an exempt intracity zone (49 CFR 391.62)
 accompanied by a Skill Performance Evaluation Certificate (SPE)
 qualified by operation of 49 CFR 391.64
The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my
findings completely and correctly, and is on file in my office.
SIGNATURE OF MEDICAL EXAMINER
TELEPHONE
DATE
MEDICAL EXAMINER’S NAME (PRINT)
 MD
 DO
 Physician Assistant
MEDICAL EXAMINER’S LICENSE OR
CERTIFICATE NO./ISSUING STATE
NATIONAL REGISTRY NO.
SIGNATURE OF DRIVER
INTRASTATE ONLY
CDL
 YES
 NO
 YES
 NO
 Chiropractor
 Advanced Practice Nurse
 Other Practitioner
DRIVER’S LICENSE NO.
STATE
ADDRESS OF DRIVER
MEDICAL CERTIFICATION EXPIRATION DATE
188

Commercial Driver Medical Examiner

Transcription

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