NATIONAL REGISTRY OF MEDICAL EXAMINER CERTIFICATION TRAINING MANUAL

Transcription

1 Federal Mtr Carrier Safety Administratin Department f Transprtatin NATIONAL REGISTRY OF MEDICAL EXAMINER CERTIFICATION TRAINING MANUAL Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 1

2 PART I Federal Mtr Carrier Safety Administratin Department f Transprtatin Histry, Missin, Gals, Ratinale Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 2

3 Federal Mtr Carrier Safety Administratin On December 9, 1999, President Clintn signed int law the Mtr Carrier Safety Imprvement Act. This act transferred the Office f Mtr Carriers frm the Federal Highway Administratin and established the Federal Mtr Carrier Safety Administratin (FMCSA). FMCSA is ne f nine U.S. Department f Transprtatin (DOT) administratins. T learn mre, visit the DOT Agencies Web page. FMCSA is headquartered in Washingtn, DC and emplys peple in 50 States and the District f Clumbia. FMCSA is led by an Administratr, Deputy Administratr, and Chief Safety Officer. The Office f Medical Prgrams is lcated under the Assciate Administratr fr Plicy and Prgram Develpment. Organizatinal Chart) FMCSA partners and custmers are serviced by field rganizatins. The rganizatins cnsist f Field Operatins, Service Centers, and State-level mtr carrier divisin ffices. Field Offices) FMCSA activities cntribute t ensuring safety in mtr carrier peratins thrugh enfrcement f safety regulatins; targeting high-risk carriers and cmmercial mtr vehicle (CMV) drivers; imprving safety infrmatin systems and CMV technlgies; strengthening CMV equipment and perating standards; and increasing safety awareness. "The FMCSA is fcused n reducing crashes, injuries, and fatalities invlving large trucks and buses." In carrying ut its safety mandate t reduce crashes, injuries, and fatalities invlving large trucks and buses, FMCSA: Develps and enfrces data-driven regulatins that balance mtr carrier (truck and bus cmpanies) safety with industry efficiency. Harnesses safety infrmatin systems t fcus n higher-risk carriers in enfrcing safety regulatins. Targets educatinal messages t carriers, cmmercial drivers, and the public. Partners with stakehlders including Federal, State, and lcal enfrcement agencies, the mtr carrier industry, safety grups, and rganized labr n effrts t reduce bus and truck-related crashes. FMCSA Web site Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 3

4 Office f Medical Prgrams "The missin f the Office f Medical Prgrams is t prmte the safety f America's radways thrugh the prmulgatin and implementatin f medical regulatins, guidelines and plicies that ensure cmmercial mtr vehicle drivers engaged in interstate cmmerce are physically qualified t d s." T prmte safety, the Office f Medical Prgrams: Oversees the natinal medical certificatin prcess fr CMV drivers wh perate in interstate cmmerce. Develps and implements medical regulatins, plicies, and prcedures. Oversees and supprts the Medical Review Bard in accrdance with the Federal Advisry Cmmittee Act. Develps and implements the natinal registry prgram a natinal medical examiner system and a linked natinal driver medical reprting system. Cnducts and versees the Agency's medical exemptin and certificate prgrams. Serves as the lead Federal agency fr the regulatin f CMV driver health and safety and cnducts relevant medical research. Natinal Registry f Certified Medical Examiners "The primary missin f the Natinal Registry f Certified Medical Examiners is t imprve highway safety by prducing trained, certified medical examiners wh can effectively determine if a cmmercial mtr vehicle driver's health meets FMCSA standards." FMCSA has established the Natinal Registry f Certified Medical Examiners (NRCME) prgram. Certified medical examiners will: Demnstrate an understanding f FMCSA physical qualificatin requirements and the demands f cmmercial driving, driver tasks, and the wrk envirnment. Perfrm driver certificatin examinatins in accrdance with FMCSA physical qualificatin requirements and medical guidelines. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 4

5 Wh Can Be A Medical Examiner The FMCSA Regulatins identify a persn wh can be a medical examiner by tw criteria: prfessinal licensing and scpe f practice that includes perfrming physical examinatins. Medical Examiner (ME) means a persn wh is licensed, certified, and/r registered, in accrdance with applicable State laws and regulatins, t perfrm physical examinatins. The term includes, but is nt limited t, dctrs f medicine and stepathy, advanced practice nurses, physician assistants and chirpractrs. 49 CFR Definitins The FMCSA rule fr the NRCME requires healthcare prfessinals t be trained, certified and listed n a natinal registry (registry) t perfrm physical examinatins f truck and bus drivers. When is Medical Certificatin Required Medical certificatin in accrdance with FMCSA physical qualificatin standards is required when the driver is perating a cmmercial vehicle in interstate cmmerce that: Has a cmbined grss vehicle weight r weight rating f 10,0001 lbs. r mre. Is designed r used t transprt 9-15 passengers (including the driver) fr cmpensatin. Is designed r used t transprt 16 r mre passengers (including the driver) whether fr cmpensatin r nt. Transprts hazardus materials in quantities that require placarding under the hazardus materials regulatins. When a driver returns frm an illness r injury that interferes with driving ability, the driver must underg a medical examinatin even if the medical examiner's certificate has nt expired. The ME is respnsible fr certifying nly drivers wh meet the physical qualificatin standards. Certificatin cannt exceed 2 years, and at the discretin f the FMCSA ME, may be less than 2 years. Federal Visin and Diabetes Exemptin Prgrams require annual medical certificatin. The CMV driver s certificate expires at midnight f the day, mnth, and year written n the certificate. There is n grace perid n the expiratin. Drivers must be re-examined and recertified t cntinue t drive legally. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 5

6 Imprtant Definitins The ME shuld becme familiar with frequently used terms in the cntext f the FMCSA Regulatins and the ME rle. Select terms frm 49 CFR and 49 CFR 40 fllw. 49 CFR Definitins Cmmercial Mtr Vehicle (CMV): Cmmercial mtr vehicle means any self-prpelled r twed mtr vehicle used n a highway in interstate cmmerce t transprt passengers r prperty when the vehicle: 1. Has a grss vehicle weight rating r grss cmbinatin weight rating, r grss vehicle weight r grss cmbinatin weight, f 4,536 kg (10,001 punds) r mre, whichever is greater; r 2. Is designed r used t transprt mre than 8 passengers (including the driver) fr cmpensatin; r 3. Is designed r used t transprt mre than 15 passengers, including the driver, and is nt used t transprt passengers fr cmpensatin; r 4. Is used in transprting material fund by the Secretary f Transprtatin t be hazardus under 49 U.S.C and transprted in a quantity requiring placarding under regulatins prescribed by the Secretary under 49 CFR, subtitle B, chapter I, subchapter C. Driver: Driver means any persn wh perates any cmmercial mtr vehicle. Interstate Cmmerce: Interstate cmmerce means trade, traffic, r transprtatin in the United States: 1. Between a place in a State and a place utside f such State (including a place utside f the United States); 2. Between tw places in a State thrugh anther State r a place utside f the United States; r 3. Between tw places in a State as part f trade, traffic, r transprtatin riginating r terminating utside the State r the United States. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 6

7 Intrastate Cmmerce: Intrastate cmmerce means any trade, traffic, r transprtatin in any State which is nt described in the term "interstate cmmerce." Medical Examiner (ME): Medical examiner means a persn wh is licensed, certified, and/r registered, in accrdance with applicable State laws and regulatins, t perfrm physical examinatins. The term includes, but is nt limited t, dctrs f medicine and stepathy, advanced practice nurses, physician assistants and chirpractrs. Mtr Carrier: Mtr carrier means a fr-hire mtr carrier r a private mtr carrier. The term includes a mtr carrier's agents, fficers, and representatives as well as emplyees respnsible fr the hiring, supervising, training, assigning, r dispatching f drivers and emplyees cncerned with the installatin, inspectin, and maintenance f mtr vehicle equipment and/r accessries. Fr purpses f subchapter B, this definitin includes the terms "emplyer" and "exempt mtr carrier." 49 CFR 40.3 What D the Terms Used in This Regulatin Mean? The Omnibus Transprtatin Emplyee Testing Act requires drug and alchl testing f safety-sensitive transprtatin emplyees in aviatin, trucking, railrads, mass transit, pipelines, and ther transprtatin industries. The DOT publishes rules n wh must cnduct drug and alchl tests, hw t cnduct thse tests, and what prcedures t use when testing. There are times when a ME may have interactins with healthcare prfessinals wh perfrm services in the drug and alchl testing prgram. Medical Review Officer (MRO): A persn wh is a licensed physician and wh is respnsible fr receiving and reviewing labratry results generated by an emplyer drug-testing prgram and evaluating medical explanatins fr certain drug test results. Substance Abuse Prfessinal (SAP): A persn wh evaluates emplyees wh have vilated DOT drug and alchl regulatins and makes recmmendatins cncerning educatin, treatment, fllw-up testing, and aftercare. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 7

8 Privacy and Medical Examinatins Regulatry requirements take precedence ver the Health Insurance Prtability and Accuntability Act (HIPAA) f There are ptential subtle interpretatins that can cause significant prblems fr the ME. What infrmatin must r can be related t r shared with the carrier is a legal issue, and if in dubt, the examiner shuld btain a legal pinin. Medical Examinatin Reprt Frm Althugh the FMCSA Regulatins d nt require the ME t give a cpy f the Examinatin Reprt frm t the emplyer, the FMCSA des nt prhibit emplyers frm btaining cpies. ME s shuld have apprpriate release frms signed by the driver if the emplyer wishes t btain a cpy f the Examinatin Reprt frm. Emplyers must cmply with applicable State and Federal laws regarding the privacy and maintenance f emplyee medical infrmatin. Fr infrmatin abut the prvisins f the Standards fr Privacy f Individually Identifiable Health Infrmatin (the Privacy Rule) cntact the U.S. Department f Health & Human Services, Office f Civil Rights at the HIPAA Web site. The HIPAA tll-free infrmatin line is: Medical Examiner s Certificate 49 CFR (g) addresses the distributin f the ME s certificate. If the ME finds that the driver is physically qualified t drive a CMV in accrdance with (b), the ME shall cmplete a certificate and furnish ne cpy t the driver and ne cpy t the mtr carrier. A release frm is nt required. The mtr carrier is required t keep a cpy f the certificate in the driver qualificatin file. The ME shuld keep a cpy f the drivers certificate n file. The driver may request a replacement cpy f the certificate frm the ME r get a cpy frm the mtr carrier. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 8

9 Medical Regulatins Summary Cde f Federal Regulatins - Law The Cde f Federal Regulatins (CFR) is the cdificatin f the general and permanent rules published in the Federal Register by the executive departments and agencies f the Federal gvernment. It is divided int 50 titles that represent brad areas subject t Federal regulatin. Title 49 is Transprtatin. Each title is divided int chapters, which usually bear the name f the issuing agency. Chapter III f Title 49 is the "Federal Mtr Carrier Safety Administratin, Department f Transprtatin." Each chapter is further subdivided int parts that cver specific regulatry areas. Part 391 is Qualificatins f Drivers and Lnger Cmbinatin Vehicle (LCV) Driver Instructrs. Large parts may be subdivided int subparts. Subpart E f Part 391 is Physical Qualificatins and Examinatins. Parts are rganized in sectins. Citatins fr the CFRs include the title, part, and sectin numbers (e.g., 49 CFR ). When the title is understd, the citatin may just include the part and sectin (e.g., ). Medical Standards/Advisry Criteria/Guidelines Standards r FMCSA Regulatins are legal requirements fr interstate cmmercial vehicles, drivers, and mtr carriers. The Regulatins are law and must be fllwed. The FMCSA prvides medical guidelines and advisry criteria t assist in the evaluatin f medical fitness t perate a cmmercial bus r truck. These guidelines are based n expert review and cnsidered best practice. The examiner may r may nt chse t use these recmmended guidelines. When the certificatin decisin des nt cnfrm with recmmendatins, the reasn(s) fr nt fllwing the medical guidelines shuld be included in the dcumentatin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 9

10 Medical Regulatins Summary Table The medical examiner shuld be familiar with the regulatins listed in the fllwing table. Regulatin 49 CFR CFR Descriptin Describes the physical qualificatin requirements fr drivers. Thirteen standards are used t determine driver medical fitness fr duty. Fur f the standards: visin, hearing, epilepsy, and diabetes mellitus have bjective disqualifiers that d nt depend n ME clinical interpretatin. These standards are the "nn-discretinary" standards. Fr the ther nine "discretinary" standards, the ME makes a clinical judgment in accrdance with the physical qualificatin requirements fr driver certificatin. Describes the respnsibilities f the ME, including general instructins fr perfrming the medical examinatin, a descriptin f driver tasks and wrk envirnment, medical advisry criteria, the sample Examinatin Reprt frm, and the ME s certificate. 49 CFR Identifies wh must have the CMV driver physical examinatin. 49 CFR Describes the prcess fr cnflict reslutin when there is a disagreement between the primary care prvider fr the driver and the ME fr the mtr carrier cncerning driver qualificatins. 49 CFR Describes the Skill Perfrmance Evaluatin (SPE) Certificatin Prgram, which is an alternative physical qualificatin standard fr the driver with a fixed musculskeletal deficit f an extremity wh cannt physically qualify t drive under (b)(1) r (b)(2). The driver must be therwise qualified t drive a CMV and meet the prvisins f the alternate standard. The first prgram t address fixed musculskeletal deficits was created and administered by the Interstate Cmmerce Cmmissin (ICC) in 1964 and was knwn as the Handicapped Driver Waiver Prgram. See Skill Perfrmance Evaluatin Certificatin Prgram (SPE) Histry. 49 CFR Describes limited exemptins fr intra-city zne drivers. 49 CFR Describes grandfathering fr certain drivers wh participated in visin and diabetes waiver study prgrams. These drivers may be certified as lng as they cntinue t meet the prvisins utlined in 49 CFR and cntinue t meet all ther qualificatin standards. 49 CFR 390 Includes general infrmatin and definitins. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 10

11 Exemptins: An exemptin prvides temprary regulatry relief frm ne r mre f the FMCSRs fr cmmercial drivers. Relief frm a regulatin is fr 2 years and may be renewed. Currently, FMCSA has tw medical Driver Exemptin Prgrams: Federal Visin Exemptin Prgram (1998). Diabetes Exemptin Prgram (September 2003). The ME cannt issue an exemptin. The rle f the ME is t determine if the driver is "therwise qualified." As part f the applicatin prcedure, the driver must btain a medical examinatin, whereby the ME determines whether the driver is "therwise qualified" if accmpanied by the Federal visin r diabetes exemptin. Bth Federal exemptins require the driver t have an annual medical examinatin fr maintenance and renewal f the exemptin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 11

12 Part II The Jb f Cmmercial Mtr Vehicle Drivers Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 12

13 FMCSA Regulates Interstate Cmmercial Operatin The FMCSA regulates interstate cmmercial peratins, including the drivers, the trucks and buses the drivers perate, the mtr carrier, and the transprtatin f hazardus materials in a quantity requiring placards. A safety risk in any ne r mre f these cmmercial peratins cmpnents can endanger the safety and health f the public. Drivers Apprximately 6 t 7 millin CMV drivers are required t cmply with FMCSA physical qualificatin standards. Thus, an estimated 3 t 4 millin physical examinatins must be perfrmed annually, with the demand increasing every year. In additin t medical fitness fr duty certificatin, ther regulatins affecting the CMV driver include drug and alchl testing, recrd keeping, hurs f service, and mre. Vehicles CMVs include trucks and buses subject t regulatins gverning inspectin, repair, and maintenance. Mtr carriers, bth fr-hire and private, must cmply with FMCSA regulatins gverning their drivers and levels f financial respnsibility. In the FMCSA Regulatins, the term "mtr carrier" refers t: Agents fr mtr carriers. Officers. Representatives. Emplyees respnsible fr the hiring, supervising, training, assigning, and dispatching f drivers. Emplyees cncerned with the installatin, inspectin, and maintenance f mtr vehicle equipment and accessries. Emplyers. Exempt mtr carriers. Mtr carriers are respnsible fr ensuring that the driver meets the general qualificatin requirements f 49 CFR 391. The driver must: Be at least 21 years ld. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 13

14 The Driver and Driver Rle The Driver Is Certified 49 CFR 391 Qualificatins f drivers and lnger cmbinatin vehicle (LCV) driver instructrs establishes the minimum qualificatins fr persns wh drive CMV s. There are seven subparts. As a ME, yu shuld be knwledgeable regarding the physical qualificatin requirements f the driver specified in Subpart E Physical qualificatins and examinatins. ME s are respnsible fr ensuring that nly drivers wh meet the Federal physical qualificatin requirements are issued an Examiner s Certificate. When ME s issue the Certificate, they are certifying that the driver is medically fit fr duty and can perfrm the driver rle that is described in the Medical Examinatin Frm (PDF). ME s may certify the driver fr a maximum f 2 years. They may als, at any time, certify the driver fr less than 2 years when examinatin indicates mre frequent mnitring is required t ensure medical fitness fr duty. Drivers are respnsible fr maintaining medical certificatin and carrying the Examiner s Certificate while perating a CMV. The Average Driver The driver ppulatin exhibits characteristics similar t the general ppulatin, including an aging wrk frce. Aging means a higher risk exists fr chrnic diseases, fixed deficits, gradual r sudden incapacitatin, and the likelihd f c-mrbidity. All f these can interfere with the ability t drive safely, thus endangering the safety and health f the driver and the public. The prfile f the average truck r bus driver: Male. Mre than 40 years f age. Sedentary. Overweight. Smker. Pr eating habits. The medical prfile: Less healthy than the average persn. Mre than tw medical cnditins. Cardivascular disease prevalent. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 14

15 The Jb f Cmmercial Driving Stress Factrs Assciated with Cmmercial Driving Types f rutes Turn-arund r shrt relay rutes allw the driver t return hme each evening. A lng relay rute requires driving 9 t 11 hurs, fllwed by at least a 10-hur, ffduty perid. Several days may elapse befre the driver returns hme. With a straight thrugh haul r crss-cuntry rute, the driver may spend a mnth n the rad, dispatched frm ne lad t the next. The driver usually sleeps in the truck and returns hme fr nly 4 r 5 days befre leaving fr anther extended perid n the rad. In team peratin, drivers share the driving by alternating 5-hur driving perids with 5-hur rest perids. Schedules Abrupt schedule changes and rtating wrk schedules may result in irregular sleep patterns and a driver beginning a trip already fatigued. Tight pickup-and-delivery schedules require bth day and night driving. Failure t meet schedules may result in a financial lss fr the driver. Lng hurs and extended time away frm family and friends may result in a lack f scial supprt. Envirnment The driver may be expsed t excessive vehicle nise, vibratin, and extremes in temperature. The driver may encunter adverse rad, weather, and traffic cnditins that cause unavidable delays. Types f carg The driver f a bus is respnsible fr passenger safety. Transprting passengers als demands effective scial skills. Lss f r shifting carg while driving can result in serius accidents. Transprting hazardus materials, including explsives, flammables, and txics, increases the risk f injury and prperty damage extending beynd the accident site. Driving and Other Tasks Stay alert when driving Driving demands sustained mental alertness and physical endurance that is nt cmprmised by fatigue r sudden, incapacitating symptms. Required cgnitive skills include prblem slving, cmmunicatin, judgment, and apprpriate behavir in bth nrmal and emergency situatins. Driving requires the ability t judge the maximum speed at which vehicle cntrl can be maintained under changing traffic, rad, and weather cnditins. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 15

16 . Use side mirrrs Mirrrs n bth sides f the vehicle are used t mnitr traffic that can mve int the blind spt f the driver. Mirrrs are als used in backing up trucks t lading and unlading areas. Sufficient lateral cervical mbility is needed fr effective use f side mirrrs Cntrl steering wheel Steering wheels f large trucks and buses are versized. The act f steering can be simulated by ffering resistance, while having the driver imitate the mtin pattern necessary t turn a 24-inch steering wheel. Manipulate dashbard switches and cntrls Large trucks and buses are cmplex vehicles with multiple dashbards, switches, and knbs. Use f these cmpnents requires adequate reach, prehensin, and tuch sensatin in hands and fingers. Shift gears The manual transmissin f a large truck may have mre than 20 gears. This requires the driver t repeatedly perfrm reciprcal mvements f bth legs crdinated with right arm and hand mvements. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 16

17 Enter and exit vehicle The driver may have t enter and exit the vehicle similar t the same way an individual climbs a ladder: by maintaining three pints f cntact fr safety. Full verhead extensin may be required t reach handhlds. Hip angle and knee flexin may have t exceed 90. Cupling and uncupling the trailers Multiple sub-tasks are perfrmed in the prcess f cupling and uncupling a trailer, including raising and lwering the trailer supprts, cnnecting air lines and electrical cables, and checking the height f the trailer kingpin. Physical demands include grip strength, upper bdy strength, full range f mtin, balance, and flexibility. Lad, secure, and unlad carg FMCSA guidelines d nt specify the number f punds a driver must be able t lift. Hwever, the Centers fr Disease Cntrl and Preventin (CDC) table f General Physical Activities Defined by Level f Intensity lists "lading and unlading a truck" as an example f a vigrus activity that requires the individual t exert greater than 6.0 metablic equivalents (MET) in perfrmance f the activity. Perfrm vehicle checks Grip strength, upper and lwer bdy strength, range f mtin, balance, and flexibility are required t inspect the engine, brakes, and carg. Visin and hearing are used t identify and interpret changes in vehicle perfrmance. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 17

18 FMCSA Cmmercial Driving Facts & Research The FMCSA Office f Analysis, Research, and Technlgy (ART) prvides the transprtatin industry and the public with analytical reprts n trends, csts, fatalities, and injuries in large truck and bus crashes. ART research and data help identify factrs that cntribute t crashes. FMCSA uses this infrmatin t develp effective cuntermeasures that will reduce the ccurrence and severity f crashes. The ART ffice prepares all ecnmic and envirnmental analysis fr FMCSA rulemakings t ensure that changes t mtr carrier regulatins are based n sund data and analysis. Crashes, Injuries, and Fatalities The FMCSA is dedicated t lwering the rate f crashes, injuries, and fatalities invlving large trucks and buses. When a fatal crash invlves a large truck, regardless f the cause, ccupants f passenger vehicles are mre likely t sustain serius injury r die than the ccupants f the truck. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 18

19 Why are the death rates f ccupants in passenger vehicles s high? The answer is fund in basic physics: injury severity equals relative velcity change. The greater the mass, the less relative velcity change. The crash f a vehicle having twice the mass with a lighter vehicle equals a six-fld risk f death t persns in the lighter vehicle. A sprt utility vehicle (SUV) weighs apprximately 4,000 punds. A laded semi-truck weighs rughly 80,000 punds. The truck has 20 times the mass f the SUV. In additin t the grievus tll in human life and survivr suffering, the ecnmic cst f these crashes is exceedingly high. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 19

20 DRIVER STATISTICS MCMIS SAFETY OUTCOMES* CY 2010 CY 2011* CY 2012* (1/1/2012-6/30/2012) CRASHES 129, ,507 59,163 Large Trucks 116, ,350 52,581 Buses 13,947 13,605 6,825 FATALITIES 4,217 4,011 1,873 Large Trucks 3,902 3,737 1,758 Buses INJURIES 80,552 78,758 37,595 Large Trucks 64,913 64,010 29,876 Buses 16,595 15,868 8,298 PROGRAM OUTPUTS FY 2010 FY 2011* FY 2012* Federal State Federal State Federal State 13,323 40,944 24,126 CARRIER REVIEWS 12,281 7,874 11,086 7,336 12,340 7,839 Hazardus Material (HM) Reviews 1,943 1,108 1, Husehld Gds Reviews Passenger Carrier Reviews** 1, , , Mtrcach Reviews** BY REVIEWS IN PHASED COMPLIANCE SAFETY ACCOUNTABILITY (CSA) STATES - Ttal Reviews Perfrmed 9,997 5,365 8,853 4,982 10,152 5,537 Full Cmpliance Reviews/On-Site Cmprehensive 8,116 4,884 4,460 3,531 2,740 2,631 Fcused Cmpliance Reviews *** *** 3,260 1,081 6,117 2,480 BY INVESTIGATIONS IN 100% CSA STATES - AK, CO, DE, GA, KS, NJ, MD, MN, MO, MT - Ttal Reviews Perfrmed 2,284 2,509 2,233 2,354 2,188 2,302 On-Site Cmprehensive Investigatins On-Site Fcused Investigatins , Off-Site Investigatins Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 20

21 Part III Examinatin Reprt Frm 1 ME Respnsibilities Driver ID & Histry Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 21

22 Medical Examiner Respnsibilities Sectin 49 CFR Medical Examinatin; Certificate f Physical Examinatin describes ME respnsibilities t determine the medical fitness-fr-duty and the issuing f Certificates t CMV drivers wh meet the physical qualificatin standards. Purpse f Interstate Cmmercial Driver Physical Examinatin FMCSA describes the peridic physical qualificatin examinatin f the interstate CMV driver t be a "medical fitness-fr-duty" examinatin. The purpse f the physical examinatin is t detect the presence f any physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a CMV safely. As a ME, yur fundamental bligatin is t establish whether a driver has a disease, disrder, cnditin r injury that creates a higher than acceptable likelihd fr gradual r sudden incapacitatin r sudden death, thus endangering public safety. Issue Is Risk Risk is the prbability f an event ccurring within a certain perid f time. Determining "acceptable risk" is bth a medical and scietal decisin. Des the Driver Pse a Risk t Public Safety? As a ME, any time yu answer yes t the abve questin, yu shuld nt certify the driver as medically fit fr duty. As yu cnduct the examinatin t determine if the driver is medically fit t perfrm the jb f cmmercial driving, yu must cnsider: Physical Cnditin. Symptms Des a medical cnditin have symptms that culd interfere with the ability t safely drive (e.g., a benign supraventricular arrhythmia that causes syncpe)? Incapacitatin Is the nset f symptms s rapid as t interfere with safe driving, can the driver stp the vehicle safely befre becming incapacitated? Is the nset f incapacitating symptms s gradual that the driver culd be unaware f diminished capabilities, thus adversely impacting safe CMV driving? Mental Cnditin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 22

23 Cgnitive Can the driver prcess envirnmental cues rapidly and make apprpriate respnses, independently slve prblems, and functin in a dynamic envirnment? Behavir Are driver interactins apprpriate, respnsible, and nnvilent? Medical Treatment. Effects Des treatment allw the driver t perfrm tasks safely? Side effects D treatment r medicatin side effects interfere with safe driving (e.g., drwsiness, dizziness, rthstatic hyptensin, blurred visin, and changes in mental status)? Medical Examiner D's As the ME, yu are examining fr medical fitness-fr-duty, nt diagnsing and treating persnal medical cnditins. Nnetheless, yu have a respnsibility t educate and refer the driver fr further evaluatin if yu suspect an undiagnsed r wrsening medical prblem. Keep the fllwing in mind DO: Cmply with FMCSA regulatins. Seek further testing/evaluatins fr thse medical cnditins f which yu are unsure. Refer the driver t his/her persnal health-care prvider fr diagnsis and treatment f ptential medical cnditins discvered during yur examinatin. Prmte public safety by educating the driver abut: Side effects caused by prescriptin and/r ver-the-cunter medicatins. Medicatin warning labels and hw t read them. The imprtance f seeking apprpriate evaluatin fr nn-disqualifying medical cnditins, especially thse that, if neglected, culd lead t illness and pssible future disqualificatin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 23

24 Examinatin Reprt Frm As a ME, yu must perfrm the driver physical examinatin and recrd the findings in accrdance with the instructins n the Examinatin Reprt frm. Yu may use an equivalent examinatin reprt frm, as lng as all elements f the Reprt frm psted in 49 CFR are included. Driver certificatin is determined based n whether r nt the driver meets the requirements f the FMCSA physical qualificatin standards cited in 49 CFR The purpse f this verview is t familiarize yu with the sectins and data elements n the Examinatin Reprt frm, including, but nt limited t: Organizatin f the frm. Required signatures. Minimum dcumentatin. grams/medical-reprt.pdf Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 24

25 REVIEW MEDICAL FORM HANDOUT MEDICAL HISTORY PAGE 1 Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 25

26 PAGE 1: Driver Identity Infrmatin and Health Histry n the Examinatin Reprt Frm The driver cmpletes the identity sectin, but yu, as the ME, must review the data t assure the infrmatin is legible and the sectin is cmpleted. Driver Name (Last, First, Middle), Verify that the rder is crrect Scial Security Number (SSN) Birthdate (Mnth, Day, Year), Verify that the rder is crrect Age, Verify that the birth date agrees with the age given. NOTE: The mtr carrier is respnsible fr ensuring that the driver meets CDL requirements and is 21 years f age befre driving an interstate cmmercial mtr vehicle (CMV). The ME can administer the driver examinatin t anyne wh requests the examinatin. Sex (Gender) Type f Certificate A cmplete physical examinatin is required fr bth a "New Certificatin" and "Recertificatin." "Fllw-up" is used if further infrmatin is needed befre yu can make a certificatin determinatin. It is a cntinuatin f yur riginal new r recertificatin examinatin. Yu need nt perfrm the entire physical examinatin again. Date f Exam The medical examiner's certificate expiratin date is calculated frm the date f the "New Certificatin" r "Recertificatin" examinatin, nt the date f any subsequent "Fllw-up" examinatin. Address Telephne Numbers Driver License N., License Class, and State f Issue Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 26

27 Health Histry Driver Cmpletes and Signs ME Reviews and Cmments Health Histry Driver Instructins The driver is instructed t indicate either an affirmative r negative histry fr each statement in the health histry by checking either the "Yes" r "N" bx. The driver is als instructed t prvide additinal infrmatin fr "Yes" respnses, including: Onset date. Diagnsis. Treating prvider cntact infrmatin. Any limitatins resulting frm a current r past medical cnditin. Medicatins used regularly r recently, including prescriptins, ver-the-cunter, and herbal supplements. Health Histry Driver Signature Verify the Driver Signs Medical Examinatin Reprt Frm By signing the Examinatin Reprt frm, the driver: Certifies that infrmatin is cmplete and true. Acknwledges that prviding inaccurate r false infrmatin r mitting infrmatin culd: Invalidate the examinatin and any certificate issued based n it. Result in the levy f a civil penalty against the driver under 49 U.S.C. 521(b)(2)(B). Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 27

28 Health Histry ME Respnsibilities The purpse f the health histry is t btain infrmatin relevant t detecting the presence f physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a CMV safely. Regulatins Yu must review and discuss with the driver any "Yes" answers Fr each "Yes" answer: Ask abut histry, diagnsis, treatment, and respnse t treatment. Explre underlying cause, precipitating events, and ther pertinent facts. Obtain additinal tests r cnsultatins, as necessary, t adequately assess the medical fitness f the driver. Review and discuss the driver s respnse t treatment and medicatins currently r recently used, including ver-the-cunter medicatins, and discuss any ptential effects and side effects that may interfere with driving. As needed, yu shuld als educate the driver regarding drug interactins with ther prescriptin and nnprescriptin drugs and alchl. Write all infrmatin n the Examinatin Reprt frm. Fr infrmatin n a specific medical cnditin, see Part IV - Physical Qualificatin Standards f this handbk. Recmmendatins Questins yu may cnsider: Des the driver have: Symptms that interfere with safe driving because f: Frequency? Duratin? Severity? Onset? Limitatins that interfere with safe driving because f: Degree f limitatin present? Likelihd f prgressive limitatin? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 28

29 Medicatins that when used have effects and side effects that interfere with driving ability, such as: Visual disturbances. Drwsiness. Hyptensin. Behaviral changes. Health Histry (Clumn 1) Overview In additin t the guidance prvided in the sectin abve, Fr each "Yes" answer, directins specific t each categry in Clumn 1 are listed belw. Feel free t ask ther questins t help yu gather sufficient infrmatin t make yur qualificatin/disqualificatin decisin. Any illness r injury in the last 5 years A driver must reprt any cnditin fr which he/she is currently under treatment. The driver is als asked t reprt any illness/injury he/she has sustained within the last 5 years, whether r nt currently under treatment. Head/brain injuries, disrders, r illnesses Ask questins that help yu determine if the driver has recurring episdes f illness r any residual physical, cgnitive, r behaviral effects that interfere with the ability t safely perate a CMV. Seizures, epilepsy Ask questins t ascertain whether the driver has a diagnsis f epilepsy (tw r mre unprvked seizures), r whether the driver has had ne seizure. Gather infrmatin regarding type f seizure, duratin, frequency f seizure activity, and date f last seizure. REMEMBER: Accrding t regulatin, a driver with an established medical histry r clinical diagnsis f epilepsy des nt meet qualificatin standards and cannt be certified. Eye disrders r impaired visin (except crrective lenses) Ask abut changes in visin, diagnsis f eye disrder, and diagnses cmmnly assciated with secndary eye changes that interfere with driving. Cmplaints f glare r near-crashes are driver respnses that may be the first warning signs f an eye disrder that interferes with safe driving. REMEMBER: The requirements fr visin screening are regulatry. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 29

30 Ear disrders, lss f hearing r balance Ask abut changes in hearing, ringing in the ears, difficulties with balance, r dizziness. Lss f balance while perfrming nn-driving tasks can lead t serius injury f the driver. REMEMBER: The screening requirement fr hearing lss is regulatry. Heart disease r acute mycardial infarctin, ther cardivascular cnditins Ask abut histry and symptms f cardivascular disease (CVD), syncpe, dyspnea, cngestive heart failure, angina, etc. NOTE: If the driver reprts symptms cnsistent with undiagnsed CVD, yu shuld refer the driver t a specialist fr further evaluatin prir t certificatin. If a driver reprts current CVD, cnsult with the driver s health-care prvider and btain dcumentatin prir t certificatin. Heart surgery Ask abut histry f heart surgery, bypass, valve replacement, pacemaker, angiplasty, and whether the driver has an implantable cardiverter defibrillatr (ICD). Obtain heart surgery infrmatin, including such pertinent reprts, cardiac catheterizatin reprts, stress tests, as needed, t adequately assess medical fitness fr duty. NOTE: If a driver gives a "Yes" answer t the questin regarding heart surgery, btain dcumentatin frm the cardilgist befre certifying. Als, FMCSA medical guidelines recmmend nt t certify the driver wh has an ICD, due t risk f syncpe and gradual r sudden incapacitatin while driving a CMV. This includes a dual pacemaker/icd, even if the ICD has nt been activated. High bld pressure Ask abut the histry, diagnsis, and treatment f hypertensin. In additin, talk with the driver abut his/her respnse t prescribed medicatins. Hypertensin alne is unlikely t cause sudden cllapse. The likelihd increases, hwever, when there is target rgan damage, particularly cerebral vascular disease. Recmmending specific therapy is beynd the scpe f the physical examinatin. As a medical examiner, thugh, yu are cncerned with the bld pressure respnse t treatment, and whether the driver is free f any effects r side effects that culd impair jb perfrmance. Muscular disease Ask the driver abut histry, diagnsis, and treatment f musculskeletal cnditins, such as rheumatic, arthritic, rthpedic, and neurmuscular diseases. Des the diagnsis indicate that the driver is at risk fr sudden, incapacitating episdes f muscle weakness, ataxia, paresthesia, hyptnia, r pain? Des the diagnsis indicate a degenerative prcess that ver time will restrict mvements and eventually interfere with the ability t safely perate a CMV? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 30

31 Shrtness f breath (SOB) Ask what activities precipitate the episdes, nature, and characteristics f SOB. Des the driver experience SOB nly with exertin r als when at rest? NOTE: Accrding t guidelines, many drivers may experience SOB while perfrming the nn-driving aspects f their wrk (e.g., lading and unlading, etc.). Hwever, mst cmmercial drivers are nt shrt f breath while driving their vehicles. SOB while driving shuld trigger a mre detailed evaluatin f the driver that can include cnsulting with an apprpriate medical specialist. Health Histry (Clumn 2) Overview Lung disease, emphysema, asthma, chrnic brnchitis Ask abut emergency rm visits, hspitalizatins, supplemental use f xygen, use f inhalers and ther medicatins, risk f expsure t allergens, etc. NOTE: Since a driver must be alert at all times, any change in mental state is in direct cnflict with highway safety. Even the slightest impairment in respiratry functin under emergency cnditins (when greater xygen supply is necessary fr perfrmance) may be detrimental t safe driving. Kidney disease, dialysis Ask abut the degree and stability f renal impairment, ability t maintain treatment schedules, and the presence and status f any c-existing diseases. REMEMBER: If the driver is n dialysis, he/she cannt drive. Digestive prblems Ask abut fd intlerance, frequent r recurrent nausea vmiting and bwel disrders. Inquire abut ver the cunter medicatin use. Diabetes r elevated bld glucse cntrlled by diet, pills, r insulin Ask abut treatment, whether by diet, ral medicatins, incretin mimetics, r insulin. REMEMBER: Drivers with insulin-treated diabetes mellitus wh are therwise qualified may apply fr a Federal exemptin. T d s, the ME must cmplete the examinatin and check the fllwing bxes: Meets standards but peridic mnitring required due t (write in: insulin treatment). One year. Accmpanied by (write in: Federal Diabetes) waiver/exemptin (circle: exemptin). Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 31

32 Nervus r psychiatric disrders (e.g., severe depressin) Refer t the guidance fund in: Regulatins - Yu must review and discuss with the driver any "Yes" answers. Lss f r altered cnsciusness Lss f cnsciusness while driving endangers the driver and the public. Yur discussin with the driver shuld include cause, duratin, treatment, and any evidence f recurrence r prir episdes f lss f r altered cnsciusness. Yu may, n a case-by-case basis, btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Health Histry (Clumn 3) Overview Fainting, dizziness Ask abut episde characteristics, including frequency, factrs leading t and surrunding an episde, and any assciated neurlgic symptms (e.g., headache, nausea, lss f cnsciusness, paresthesia). Sleep disrders, pauses in breathing while asleep, daytime sleepiness, lud snring Ask the driver abut sleep disrders. Als ask abut such symptms as daytime sleepiness, lud snring, r pauses in breathing while asleep. When indicated, yu shuld screen fr sleep disrders. Strke r paralysis Nte any residual paresthesia, sensry deficit, r weakness as a result f strke and cnsider bth time and risk fr seizure. Missing r impaired hand, arm, ft, leg, finger, te Determine whether the missing limb affects driver pwer grasping, prehensin, r ability t perfrm nrmal tasks, such as braking, clutching, accelerating, etc. NOTE: The Skilled Perfrmance Evaluatin (SPE) is designed fr fixed deficits f the extremities and cannt be used fr deficits caused by prgressive disrders. The SPE is applicable nly fr fixed deficits f the extremities. The underlying cause fr the fixed deficit (e.g., trauma, cerebral palsy, r a birth defect) des nt affect eligibility t apply fr an SPE. Hwever, the lcatin f the deficit must be an extremity, nt the neck r trs. SPE certificatin cannt be used as an alternative standard fr deficits caused by prgressive diseases. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 32

33 Spinal injury r disease Refer t the guidance fund in Regulatins - Yu must review and discuss with the driver any "Yes" answers. Chrnic lw back pain Ask abut the degree f pain. Hw des the pain affect the ability f the driver t perfrm driving and nn-driving tasks? What des the driver d t alleviate pain? Des the treatment interfere with safe driving? Regular, frequent alchl use Ask abut driver cnsumptin f alchl, including quantity and frequency, r use such tls as the CAGE questinnaire t screen fr pssible alchl-use prblems. Yu shuld refer the driver wh shws signs f a current alchlic illness t a specialist. Narctic r habit-frming drug use Explre the use f the medicatin, whether r nt it is prescribed, and the medicatin s effect n driver reactin time, ability t fcus, and cncentratin. Ask whether the medicatin causes drwsiness, fatigue, r sleepiness. NOTE: The medical examiner has the authrity t disqualify a driver if he/she believes that the medicatin the driver is taking adversely impacts the ability t safely perate a CMV. Health Histry ME Cmments At a minimum, yur cmments shuld include: Nature f a psitive histry and the effect n driving ability. Discussin abut medicatin and/r treatment effects and side effects that might interfere with driving ability. Include a cpy f any supplementary medical reprts btained t cmplete the health histry. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 33

34 Part IV Examinatin Standards Qualificatin/Disqualificatin The 13 Standards Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 34

35 Regulatins Versus Medical Guidelines As a ME it is imprtant fr yu t distinguish between medical standards (49 CFR ) and medical guidelines. Regulatins r standards are laws and must be fllwed. Whereas guidelines, such as advisry criteria and medical cnference reprts are recmmendatins. While nt law, the guidelines are intended as best practices fr medical examiners. Guidelines have been issued by the FMCSA t prvide additinal infrmatin and are based n medical literature. If yu chse nt t fllw the guidelines, the reasn(s) fr the variatin shuld be dcumented. Yu are respnsible fr determining if the CMV driver is medically qualified and is safe t drive under the FMCSA Regulatins The physical qualificatin regulatins fr CMV drivers in interstate cmmerce are fund at Sectin (b) f the FMCSA Regulatins. The advisry criteria under are recmmendatins t help yu as a medical examiner perfrm medical examinatins and determine the medical fitness fr duty f a driver. They are accessible n the FMCSA Web site at: Medical Advisry Criteria fr Evaluatin Under 49 CFR Part Onging Standards & Guidelines Review Prcess FMCSA has an nging prcess fr reviewing all Federal medical standards and guidelines used t determine driver medical fitness fr duty. T ensure that these regulatins and guidelines are evidence-based, FMCSA uses a number f methds fr gathering medical data, including, but nt limited t: Agency expert analyses f Federal data and ther relevant internatinal, natinal, and State data. Interagency, natinal, and internatinal regulatry analyses. Evidence reprts. Medical Expert Panels (MEPs). Medical Review Bard (MRB), a cmmittee established in accrdance with the Federal Advisry Cmmittee Act. First, FMCSA frmulates questins relating t a specific medical cnditin and the assciated impact n driving. FMCSA then gathers infrmatin thrugh a systematic review f the available scientific literature. The findings are summarized in evidence reprts that reflect current diagnstic and therapeutic medical advances. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 35

36 Fr sme tpics, FMCSA cnvenes an MEP. The members f the MEP vary accrding t the specific tpic and panel expertise. The task f the MEP is t prvide an pinin fr cnsideratin by FMCSA. Evidence reprts, executive summaries, and MEP pinins are psted n the FMCSA Web site at Reprts Hw Medical Cnditins Impact Driving. The MRB meets three t fur times each year n specific tpics. The MRB independently reviews evidence reprts and if an MEP was cnvened, als reviews the MEP pinin. The MRB deliberates and prpses recmmendatins fr cnsideratin by FMCSA. MRB prceedings and public meetings schedule are psted n the MRB Web site. FMCSA cnsiders the evidence reprts, the MEP pinin, and the recmmendatins frm the MRB when reviewing medical standards and guidelines. FMCSA als cnsiders ther factrs such as feasibility and impact. FMCSA psts infrmatin regarding prpsed changes t the standards and guidelines n the FMCSA Medical Prgram Web page. Prpsed changes t guidelines will accmpany the standards as guidance and are subject t public ntice-and-cmment rulemaking. This Medical Examiner Handbk will be updated as new standards and guidelines are apprved. 49 CFR (b) Standards Review 49 CFR Physical qualificatins fr drivers describes the medical qualificatin standards that an individual must meet in rder t be qualified t perate an interstate CMV. Yur knwledge f the physical and mental demands f cmmercial driving and yur medical judgment determine whether a particular cnditin interferes with driver ability f the persn t perate a CMV safely. As the ME, yur fundamental bligatin is t establish whether a driver has a disease r cnditin that increases the risk fr sudden death r incapacitatin, thus endangering public safety. The examinatin is based n infrmatin prvided by the driver (histry), bjective data (physical examinatin), and additinal testing requested by the ME. The assessment shuld reflect physical, psychlgical, and envirnmental factrs. Medical certificatin depends n a cmprehensive medical assessment f verall health and infrmed medical judgment abut the impact f single r multiple cnditins n the whle persn. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 36

37 Part IV Examinatin Reprt Frm 2 The Fur Tests Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 37

38 REVIEW MEDICAL REPORT FORM FOUR TESTS PAGE 2 Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 38

39 PAGE 2: Testing n the Examinatin Reprt Frm Visin NOTE: Trained assistive persnnel may perfrm visin screening tests, hearing tests, measure and recrding f BP and pulse, height and weight, and the measurement and recrding f urine dipstick results. Hwever, the ME must sign the Examinatin Reprt frm. By signing the Reprt frm, the ME is taking respnsibility fr and attesting t the validity f all dcumented test results. Visin Medical Examiner Instructins T meet the Federal visin standard, the driver must meet the qualificatin requirements fr visin with bth eyes. Regulatins A driver must have: Distant visual acuity f at least 20/40 (Snellen) in each eye, with r withut crrective lenses. Distant bincular visual acuity f at least 20/40 (Snellen) in bth eyes, with r withut crrective lenses. Field f visin f at least 70 in the hrizntal meridian in each eye. Ability t recgnize and distinguish amng the clrs f traffic signals and devices shwing the standard red, amber, and green. Administer Visin Screening Tests Have drivers wh wear crrective lenses fr driving wear crrective lenses fr testing. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 39

40 Evaluate drivers wh wear cntact lenses fr gd tlerance and adaptatin t cntact lens usage. If needed, request a visin examinatin by a specialist using advanced visin testing equipment t evaluate driver visin adequately. Disqualifying Visin Mncular visin. Use f cntact lenses when ne lens crrects distant visual acuity and the ther lens crrects near visual acuity. Use f telescpic lenses. Failure t meet any part f the visin testing criteria with ne eye r bth eyes. NOTE: Sme drivers with mncular visin may be able t be certified if therwise medically fit fr duty and they are granted a Federal visin exemptin certificate. Specialist Visin Certificatin The visin testing and certificatin may be cmpleted by an phthalmlgist r ptmetrist. A specialist visin examinatin may be: A requirement fr btaining and renewing a medical exemptin. Necessary t btain adequate evaluatin f visin with specialized diagnstic equipment. When the visin test is dne by an phthalmlgist r ptmetrist, that prvider must fill in the date, name, telephne number, license number, State f issue, and sign the examinatin frm. Additinally, ensure that any attached specialist reprt includes all required examinatin and prvider infrmatin. NOTE: Visin is the nly prtin f the driver physical examinatin that can be perfrmed and certified by a prvider ther than a ME. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 40

41 Visin - 49 CFR (b)(10) Summary f regulatin "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has distant visual acuity f at least 20/40 (Snellen) in each eye withut crrective lenses r visual acuity separately crrected t 20/40 (Snellen) r better with crrective lenses, distant bincular acuity f at least 20/40 (Snellen) in bth eyes with r withut crrective lenses, field f visin f at least 70º in the hrizntal meridian in each eye, and the ability t recgnize the clrs f traffic signals and devices shwing standard red, green, and amber." The required tests measure visual acuity, peripheral hrizntal visual fields, and clr. Visual acuity is measured in each eye individually and bth eyes tgether. Distant visual acuity f at least 20/40 (Snellen) in each eye, with r withut crrective lenses. Distant bincular visual acuity f at least 20/40 (Snellen) in bth eyes, with r withut crrective lenses. Field f visin f at least 70 in the hrizntal meridian in each eye. Clr visin must be sufficient t recgnize traffic signals and devices shwing the standard red, amber, and green traffic signal clrs. When crrective lenses are used t meet visin qualificatin requirements, the crrective lenses must be used while driving. A ME, phthalmlgist, r ptmetrist may perfrm and certify visin test results. The ME determines driver certificatin status. Mncular visin is disqualifying. Driving and Public Safety Adequate central and peripheral visin are necessary fr safe driving. The driver must perceive the relative distance f bjects, and react apprpriately t vehicles in adjacent lanes r reflected in the mirrrs, t pass, make lane changes, and avid ther vehicles n the rad. The visual demands f driving are magnified by vehicles that have larger blind spts, lnger turning radiuses, and increased stpping times. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 41

42 Health Histry Visin questins asked in the health histry. Eye disrders? Impaired visin (d nt include crrective lenses)? Imprtant visin questins t ask. Symptms related t r caused by eye diseases? Use f medicatins that have side effects that can affect safe driving? Physical Examinatin Examine the eyes fr: Pupillary equality. Reactin t light and accmmdatin. Ocular mtility. Ocular muscle imbalance. Extracular mvements. Nystagmus. Exphthalms. Required Tests Required visin screening tests include central visual acuity, peripheral visin, and clr visin. Central visual acuity The Snellen chart r the Titmus Visin Tester measure static central visin acuity. The requirement fr central distant visual acuity is at least 20/40 in each eye and distant bincular visual acuity f at least 20/40. Test results must be recrded in Snellen-cmparable values. Eyeglasses r cntact lenses may be wrn t meet distant visual acuity requirements. When crrective lenses are wrn t meet visin qualificatin requirements, crrective lenses must be wrn while driving. Snellen Distant Acuity Test. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 42

43 Peripheral visin The requirement fr peripheral visin is at least 70 in the hrizntal meridian fr each eye. In the clinical setting, sme frm f cnfrntatinal testing is ften used t evaluate peripheral visin. When test results are incnclusive, the evaluatin shuld be perfrmed by a specialist with equipment capable f precise measurements. Recmmended Prtcl fr Screening the Visual Field. Clr visin The clr visin requirement is met by the ability t recgnize and distinguish amng red, amber, and green, the standard clrs f traffic cntrl signals and devices. True clr perceptin is nt required. Additinal Evaluatin/Ancillary Tests Eye trauma and phthalmic disease can adversely impact visual perfrmance and interfere with safe driving. Sme phthalmic diseases are seen mre frequently with increased age r are secndary t ther diseases such as diabetes mellitus r athersclersis. The clinical setting may nt prvide the necessary equipment t evaluate phthalmic diseases adequately. The medical examiner determines if the visin symptms and signs r underlying disease require evaluatin by an phthalmlgist r ptmetrist. The medical examiner then cnsiders the dcumented results and the specialist pinin when determining if the visin meets qualificatin requirements. Select Ophthalmic Diseases Cataracts. Glaucma. Macular degeneratin. Retinpathy. Certificatin and Dcumentatin The qualified driver meets all f the fllwing requirements: Distant acuity f at least 20/40 in each eye, Bincular acuity f at least 20/40, Hrizntal field f visin f at least 70 measured in each eye, and The ability t recgnize and distinguish amng traffic cntrl signals and devices shwing standard red, amber, and green clrs. The ME may certify the driver fr up t 2 years. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 43

44 The driver wh wears crrective lenses t meet the visin qualificatin requirements must wear crrective lenses while driving. The ME marks the "wearing crrective lenses" checkbx n bth the Examinatin Reprt frm and certificate. The examiner shuld advise the driver t carry a spare set f eyeglasses. Mncular visin Mncular visin ccurs when the visin requirements are met in nly ne eye, with r withut the aid f crrective lenses, regardless f cause r degree f visin lss in the ther eye. In lw illuminatin r glare, mncular visin causes deficiencies in cntrast recgnitin and depth perceptin cmpared t bincular visin. The ME shuld cmplete the certificatin examinatin f the driver with mncular visin and determine if the driver is therwise qualified. The driver with mncular visin wh is therwise qualified may want t apply fr a Federal visin exemptin. The therwise medically qualified driver with a Federal visin exemptin At the annual recertificatin examinatin, the driver presents a valid visin exemptin and a cpy f the specialist eye examinatin reprt befre receiving the ME's certificate. The ME may certify the driver fr up t 1 year. Mark the "accmpanied by" exemptin checkbx and write "visin" t identify the type f Federal exemptin. The therwise medically qualified driver applying fr a Federal visin exemptin The driver applying fr a visin exemptin shuld include a cpy f the Examinatin Reprt frm and certificate with the applicatin t the Federal Visin Exemptin Prgram. Certify the driver fr up t 1 year. Mark the "accmpanied by" exemptin checkbx and write "visin" t identify the type f Federal exemptin. The ME des nt issue a Federal visin exemptin. Bth the ME's certificate and Federal visin exemptin are required befre the driver with mncular visin can legally drive a cmmercial vehicle in interstate cmmerce. Federal Visin Exemptin Prgram Qualified by Operatin f 49 CFR : "Grandfathered." Cntact the Federal Visin Exemptin Prgram r call Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 44

45 Hearing Hearing Medical Examiner Instructins T meet the Federal hearing standard, the driver must successfully cmplete ne hearing test with ne ear. Regulatins A driver must: First perceive a frced, whispered vice in ne ear at nt less than five feet, OR Nt have an average hearing lss in ne ear greater than 40 decibels (db) at 500 hertz (Hz), 1,000 Hz, and 2,000 Hz. Administer Hearing Test r Tests Administer either hearing test first: Frced whisper test. Audimetric test. If the driver: Passes the initial hearing test: D nt administer the ther test. Fails the initial hearing test: D administer the ther hearing test. A driver may use a hearing aid t meet the standard. Recrd use f a hearing aid. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 45

46 If the driver uses a hearing aid while testing, mark the Check if hearing aid used fr tests bx. If the driver must use a hearing aid t meet standard, mark the Check if hearing aid required t meet standard bx. Recrd Hearing Tests Results Frced whisper test Recrd the distance, in feet, at which a whispered vice is first heard. Audimetric test Recrd hearing lss in db fr 500 Hz, 1,000 Hz, and 2,000 Hz accrding t the American Natinal Standards Institute (ANSI). NOTE: Cnvert Internatinal Organizatin fr Standardizatin (ISO) audimetric test results t ANSI by: Subtracting 14 db frm ISO fr 500 Hz. Subtracting 10 db frm ISO fr 1,000 Hz. Subtracting 8.5 db frm ISO fr 2,000 Hz. Hearing Hearing Test Example In the example abve, the examiner has dcumented the test results fr bth hearing tests. The frced whisper test was administered first, and hearing measured by the test failed t meet the minimum five feet requirement in bth ears. Therefre, the medical examiner als administered an audimetric test, resulting in: Right ear = 98/3 = 32.6 = PASS Left ear = 133/3 = 44.3 = FAIL The hearing standard is met because the average hearing lss in the right ear is less than 40 db when measured with an audimeter. This driver passed ne hearing test in ne ear. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 46

47 Hearing 49 CFR (b)(11) Summary f regulatin "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn First perceives a frced whispered vice in the better ear at nt less than 5 feet with r withut the use f a hearing aid r, if tested by use f an audimetric device, des nt have an average hearing lss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with r withut a hearing aid when the audimetric device is calibrated t American Natinal Standard (frmerly ASA Standard) Z " The required tests screen fr hearing lss in the range f nrmal cnversatinal tnes. Tw tests are used t screen hearing: a frced whisper test AND/OR an audimetric test. Either test may be administered first. Test bth ears. Administratin f the secnd test may be mitted when the test results f the initial test meet the hearing requirement fr that test. Hearing requirements are: First perceive a frced whispered vice, in ne ear, at nt less than five feet. OR Have an average hearing lss, in ne ear, less than r equal t 40 decibels (db). When a hearing aid is used t meet the hearing qualificatin requirement, the hearing aid must be used while driving. Disqualify when bth the frced whisper test AND the audimetric test are failed. Driving and Public Safety Hearing plays a rle in safe driving. Hearing warning sunds, such as hrns, train signals, and sirens may allw the driver t react t a ptential hazard befre it is visible. An auditry alarm r changes in the usual sund f the engine r vehicle carriage may be the first indicatin that the vehicle may require maintenance. Hearing lss can interfere with cmmunicatin between the driver and ther peple such as dispatchers, lading dck persnnel, passengers, and law enfrcement fficers. Balance is required fr safe driving and task perfrmance (e.g., vehicle inspectins, securing lads) and when getting int, and ut f, trucks and buses. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 47

48 Health Histry Hearing questins that are asked in the health histry. Ear disrders? Lss f hearing? Lss f balance? Imprtant questins t ask. Symptms related t r caused by ear disease? Use f medicatins? Physical Examinatin Examine the ears fr: Scarring f tympanic membranes r signs f middle ear disease. Occlusin f the external ear canal. Perfrated eardrums. Nte and discuss abnrmal findings, including the impact n driving and certificatin. Hearing lss can be a symptm f a disease rather than a discrete disrder. In sme cases, hearing lss may be treated and reversed. Required Tests The frced whisper test and audimetry are used t determine certificatin. These tests measure hearing lss using the frequencies fund in nrmal cnversatin. Either test can be administered first. Administratin f bth tests is required nly when the initial test results fr bth ears fail t meet the hearing requirement. A hearing aid may be used during frced whisper testing. When a driver wh wears a hearing aid is unable t pass a frced whisper test, referral t an audilgist, tlarynglgist, r hearing aid center may be required. The hearing qualificatin requirement fr: Frced whisper test First perceives a frced whispered vice. In ne ear. At nt less than five feet. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 48

49 Audimetric test Has an average hearing lss (average f test results fr 500 hertz (Hz), 1,000 Hz, and 2,000 Hz). In ne ear. Less than r equal t 40 db. Additinal Evaluatin/Ancillary Tests Ear trauma and tic disease can adversely impact hearing and/r balance and interfere with safe driving and perfrmance f related tasks. When findings are incnclusive regarding medical fitness fr duty, ancillary tests and/r additinal evaluatin by a specialist, usually an audilgist r tlarynglgist, may be required t btain sufficient medical infrmatin t determine certificatin status. Select Otic Diseases and Cnditins Meniere's disease. Vertig. Labyrinthine fistula. Nnfunctining labyrinth. FMCSA medical reprts are available n the FMCSA Web site. Certificatin and Dcumentatin The qualified driver, with r withut the use f a hearing aid: First perceives a frced whispered vice, in ne ear, at nt less than five feet. OR Has an average hearing lss, in ne ear, less than r equal t 40 db at 500 Hz, 1,000 Hz, and 2,000 Hz. The ME may certify the driver fr up t 2 years. The driver wh uses a hearing aid t qualify must wear a hearing aid while driving. The ME marks the "wearing hearing aid" checkbx n bth the Examinatin Reprt frm and the certificate. The examiner shuld advise the driver t carry a spare pwer surce fr the hearing aid. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 49

50 Bld Pressure & Pulse Rate Bld Pressure/Pulse Rate Medical Examiner Instructins Regulatins Yu must measure: Bld Pressure (BP) Only BP readings taken during the driver physical r fllw-up examinatins may be used fr certificatin decisins. BP greater than 139/89 must be cnfirmed with a secnd measurement taken later during the examinatin. Recrd additinal BP measurement in yur cmments n the Examinatin Reprt frm. Pulse Dcument pulse rhythm by marking the Regular r Irregular bx. Recrd pulse rate. Recrd additinal pulse characteristics in yur cmments n the Examinatin Reprt frm. NOTE:.When BP, pulse rate, r bth are significant factrs in yur decisin nt t certify a driver, it is prudent fr yu t measure the readings yurself. Bld Pressure/Pulse Rate Stages f Hypertensin Guidelines Table The instructins fr ME s fund in 49 CFR Bld pressure (BP) stipulate that mre frequent mnitring is apprpriate when a driver has hypertensin at examinatin time r is being treated fr hypertensin. The Bld Pressure/Pulse Rate sectin f the Examinatin Reprt frm has a table that summarizes the guidelines fr BP and is equivalent t three stages f hypertensin. A ne-time, three-mnth medical certificate is granted in tw cases: where the driver has a BP that is equivalent t Stage 2 hypertensin, r a driver that was certified with Stage 1 hypertensin has nt achieved a BP less than r equal t 140/90 at recertificatin. This three-mnth certificate is a ne-time issuance fr the recertificatin perid and is nt intended t mean nce in the driver s lifetime. NOTE: These are recmmendatins. The ME may use his/her clinical expertise and results f the Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 50

51 individual driver examinatin t determine the length f time between recertificatin examinatins. The fllwing table crrespnds t the first tw clumns f the recmmendatin table in the Examinatin Reprt frm. Clumn ne has the bld pressure readings, and clumn tw has the categry classificatin. Reading / / greater than r equal t 180/110 Categry Stage 1 hypertensin Stage 2 hypertensin Stage 3 hypertensin When a BP reading is a value where the individual systlic and diastlic readings are in different stages, yu shuld classify the reading by the higher stage. Fr example, 168/94 and 148/104 are bth examples f Stage 2 hypertensin. The next table crrespnds t clumns three and fur f the recmmendatin table in the Examinatin Reprt frm. Use the Expiratin Date and Recertificatin clumns t assist yu in determining driver certificatin decisins. Expiratin Date Recertificatin 1 year 1 year if less than r equal t 140/90 One-time certificate fr 3 mnths 6 mnths frm date f examinatin if less than r equal t 140/90 1 year frm date f examinatin if less than r equal t 140/90 6 mnths if less than r equal t 140/90 Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 51

52 A driver with Stage 3 hypertensin (greater than r equal t 180/110) is at an unacceptable risk fr an acute hypertensive event and shuld be disqualified. Yu may recnsider the driver fr certificatin fllwing effective treatment fr hypertensin evidenced by BP stabilized at less than r equal t 140/90. The 6-mnth expiratin and recertificatin dates apply t the driver with a knwn histry f Stage 3 hypertensin, wh has an acceptable BP at examinatin time, and wh tlerates treatment with n side effects affecting safe peratin f a CMV. High Bld Pressure - 49 CFR (b)(6) Summary f regulatin "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n current clinical diagnsis f high bld pressure likely t interfere with his/her ability t perate a cmmercial mtr vehicle safely." 49 CFR (f) Bld Pressure (BP) "If a driver has hypertensin and/r is being medicated fr hypertensin, he r she shuld be recertified mre frequently. An individual diagnsed with Stage 1 hypertensin (BP is 140/90 159/99) may be certified fr ne year. At recertificatin, an individual with a BP equal t r less than 140/90 may be certified fr ne year; hwever, if his r her BP is greater than 140/90 but less than 160/100, a ne-time certificate fr 3 mnths can be issued. An individual diagnsed with Stage 2 (BP is 160/ /109) shuld be treated and a ne-time certificate fr 3-mnth certificatin can be issued. Once the driver has reduced his r her BP t equal t r less than 140/90, he r she may be recertified annually thereafter. An individual diagnsed with Stage 3 hypertensin (BP equal t r greater than 180/110) shuld nt be certified until his r her BP is reduced t 140/90 r less, and may be recertified every 6 mnths." Relevance t Driving Americans With Hypertensin Accrding t the Third Natinal Health and Nutritin Examinatin Survey, 29% f all U.S. adults 18 years and lder have BP greater than r equal t 140/90 r are taking medicatin fr hypertensin. The prevalence f hypertensin is nearly equal fr men and wmen. Amng adults with hypertensin, 78% are aware f their cnditin, 68% are treated with antihypertensive medicatin, and 64% achieve BP less than 140/90 with treatment. Risks Assciated With Hypertensin Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 52

53 Hypertensin alne is unlikely t cause sudden cllapse; hwever, hypertensin is a ptent risk factr fr the develpment f mre serius cardivascular disease (CVD), peripheral vascular disease, and chrnic renal insufficiency. BP greater than r equal t 140/90 is deemed high fr mst individuals withut ther significant cardivascular risk factrs. In individuals ranging frm 40 t 89 years f age, fr every 20 mm Hg systlic r 10 mm Hg diastlic increase in BP, there is a dubling f mrtality frm bth ischemic heart disease and strke. The relatinship between BP and risk f a CVD event is cntinuus, cnsistent, and independent f ther risk factrs. Bth elevated systlic and diastlic BP are risk factrs fr crnary heart disease (CHD). Cmmercial Drivers at Greater Risk fr Develping Hypertensin Once in the prfessin, CMV drivers have a greater prpensity t develp hypertensin than their peers in ther prfessins. The Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers includes data frm Ragland, et al., demnstrating that the percentage f drivers with hypertensin increased frm 29% in drivers with fewer than 10 years f driving experience, t 32% in drivers with years f experience, and t 39% in drivers with mre than 20 years f driving experience. As the years f experience rise, part f the increase in hypertensin may relate t accmpanying aging, increase in bdy mass, r decline in physical activity. Effective Treatment Reduces Risk High BP can be a mdifiable CVD risk factr. Lifestyle mdificatin and pharmactherapy are the mainstays f antihypertensive treatment regimens. Effective hypertensin management reduces cardivascular mrbidity and mrtality. The Chicag Heart Assciatin Detectin Prject in Industry fund that antihypertensive therapy reduces the incidence f strke, mycardial infarctin, and heart failure. Key Pints fr High BP/Hypertensin Medical Examinatin A current diagnsis f hypertensin exists when ne r mre antihypertensive agents are used t cntrl high BP. When antihypertensive medicatin is used t treat an underlying cnditin ther than high BP, certificatin is based n the underlying cnditin and tlerance t the medicatin. The Examinatin Reprt frm includes questins abut the health histry f the driver and requires measuring BP. Additinal questins shuld be asked t supplement the infrmatin requested n the Examinatin Reprt frm. Yu may ask abut symptms f hypertensin and use f antihypertensive medicatins. It is generally nt the rle f the medical examiner t determine treatment fr the disease. Yu shuld evaluate fr ther clinical cardivascular diseases, including CHD, heart failure, and left ventricular hypertrphy, as well as strke r transient ischemic attack, peripheral artery disease, retinpathy, nephrpathy, and ther target rgan damage. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 53

54 Regulatins Des the driver: Have high BP? Take hypertensive medicatin? Recmmendatins Questins yu may cnsider Des the driver have: Cntact infrmatin fr the treating prvider and a medical release frm? Symptms related t r caused by high BP? Limitatins resulting frm the disease r treatment? Lifestyle risk factrs, particularly mdifiable behavirs and cnditins (e.g., smking, besity, and/r lack f exercise)? Uncntrlled hypertensin while using three r mre antihypertensive medicatins at clse t maximum dsages? If the respnse is yes, an evaluatin fr secndary hypertensin may be apprpriate. Regulatins Fr every certificatin and recertificatin examinatin yu must: Measure BP. Cnfirm BP greater than 139/89 with a secnd measurement taken later during the examinatin. Check pulse rate, strength, and rhythm. NOTE: Under the supervisin f the medical examiner, trained assistive persnnel may measure and recrd the BP; hwever, it is prudent fr the medical examiner t cnfirm disqualifying BP persnally. Recrd Recrd BP and pulse in Sectin 5 f the Medical Examinatin Reprt frm. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 54

55 NOTE: The table n the right side f Sectin 5 summarizes certificatin decisins based n the stages f hypertensin. The first clumn shws the BP ranges and the secnd clumn reflects the crrespnding stage f hypertensin. When the systlic and diastlic readings are in different stages f hypertensin, classify BP as the higher stage (e.g., BP f 164/96 r 154/104 is classified as stage 2 hypertensin). Hypertensin Guidance/Advisry Criteria Essential Hypertensin Secndary Hypertensin The cmplete text f the medical cnference reprts can be accessed frm FMCSA Medical Reprts. Labratry and Other Test Findings Labratry and Other Test Findings Medical Examiner Instructins Regulatins Yu must perfrm a urinalysis (dip stick) Test fr: Specific gravity Prteinuria Hematuria Glycsuria Additinal Tests and/r Evaluatin frm a Specialist Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 55

56 Abnrmal dipstick readings may indicate a need fr further testing. As a ME, yu shuld evaluate test results and ther physical findings t determine the next step. Fr example, glycsuria may prmpt yu t btain a bld glucse test. If the urinalysis, cmbined with ther medical findings, indicates the ptential fr renal dysfunctin, yu shuld btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Dcument all additinal test results and include the results in yur cmments, including whether r nt the health f the driver affects the ability t safely perate a CMV. Attach any additinal medical reprts btained t the Examinatin Reprt frm. NOTE: Testing fr cntrlled substances is nt part f the physical qualificatins fr the CMV driver examinatin prcess. Testing fr cntrlled substances falls under a different regulatin. Hwever, if yu suspect a need fr drug/alchl testing, cntact the FMCSA, r the mtr carrier directly, fr infrmatin n cntrlled substances and alchl testing under Part 382 f the FMCSA Regulatins. Specific questins may be directed t the FMCSA Field Office in yur State r call FMCSA at Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 56

57 Part IV Examinatin Reprt Frm 3 Physical Exam Exemptins & Exceptins Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 57

58 REVIEW MEDICAL REPORT PHYSICAL EXAMINATION PAGE 3 QUESTIONS 7-12 Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 58

59 PAGE 3: Physical Exam n the Examinatin Reprt Frm Physical Examinatin Recrd Driver Height and Weight Regulatins Yu must measure and recrd driver height (inches) and weight (punds) The physical qualificatin standards d nt include any maximum r minimum height and weight requirements. Yu shuld cnsider height and weight factrs as part f the verall driver medical fitness fr duty. Physical Examinatin ME Respnsibilities The general purpse f the physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the driver s ability t perate a CMV safely. This examinatin is fr public safety determinatin and is cnsidered by the FMCSA t be a "medical fitness fr duty" examinatin. Regulatins Yu must perfrm the described physical examinatin The physical examinatin shuld be cnducted carefully and must, at a minimum, be as thrugh as the examinatin f bdy systems utlined in the Examinatin Reprt frm. Fr each bdy system, mark "Yes" if abnrmalities are detected, r "N" if the bdy system is nrmal. Yu must dcument abnrmal findings n the Examinatin Reprt frm, even if nt disqualifying. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 59

60 Start yur cmments using the number t indicate the bdy system (e.g., 2 fr eyes r 8 fr vascular system). Yur cmments shuld: Indicate whether r nt the abnrmality affects driving ability. Indicate if additinal evaluatin is needed t determine medical fitness fr duty. Include a cpy f any supplementary medical evaluatin btained t adequately assess driver health. Dcument yur discussin with the driver, which may include advice t seek additinal evaluatin f a cnditin that is nt disqualifying but culd, if neglected, wrsen and affect driving ability. Indicate whether r nt the bdy has cmpensated fr an rganic disease adequately t meet physical qualificatin requirements. Bdy System (Clumn 1) CHECK FOR: 1. General Appearance Observe and nte n the Examinatin Reprt frm any abnrmalities with psture, limps, r tremrs. Observe and nte driver affect and verall appearance. Nte driver demeanr and whether respnses t questins indicate ptential adverse impact n safe driving. Is the driver markedly verweight? If yes, what are the clinical and safety implicatins when integrated with all ther findings? Are there signs f current alchl r drug abuse? If yes, refer the driver t a specialist fr evaluatin. After successful cunseling and/r treatment, a driver may be cnsidered fr certificatin, as lng as n residual limitatins exist that culd interfere with the ability t safely perate a CMV. 2. Eyes At a minimum, yu must check fr pupillary equality, reactin t light and accmmdatin, cular mtility, cular muscle imbalance, extracular mvement, nystagmus, and exphthalms. Des yur examinatin find any abnrmality that interferes with driving ability? Is an eye abnrmality an indicatr that additinal evaluatin, perhaps by a specialist, is needed t assess the nature and severity f the underlying cnditin? NOTE: Special diagnstic equipment may be needed t adequately assess a driver with a knwn diagnsis r wh is at risk fr retinpathy, cataracts, aphakia, glaucma r macular degeneratin. Referral t a visin specialist may be required. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 60

61 3. Ears Yu shuld check fr evidence f any aural disease r cnditin. At a minimum, yu must check fr scarring f the tympanic membrane, cclusin f the external canal, and perfrated eardrums. Des yur examinatin find abnrmalities that might accunt fr hearing lss r a disturbance in balance? Shuld the driver cnsult with a primary care prvider r hearing specialist fr pssible treatment that might imprve hearing test results? The presence f sme disrders, such as Meniere's disease, may interfere significantly with driving ability and perfrmance f CMV driver tasks. In this case, guidelines recmmend t nt certify the driver. 4. Muth and Thrat Yu shuld be alert t findings that suggest ral disease r impaired rpharynx airflw. Des a cnditin exist that shuld be evaluated fr treatment r further diagnstic testing prir t certificatin as a CMV driver? 5. Heart Yu must examine the heart fr murmurs, extra sunds, enlargement, and a pacemaker r implantable cardiverter defibrillatr. Check the lwer extremities fr pitting edema and ther signs f cardiac disease. Des yur examinatin find any abnrmalities that indicate the driver may have a cardivascular disrder accmpanied by and/r likely t cause symptms f syncpe, dyspnea, cllapse, r cngestive cardiac failure? Des a cnditin r treatment require lng-term fllw-up and mnitring t ensure that the cnditin is stabilized r that treatment is effective and well tlerated? NOTE: There are n wrk restrictins permitted. The cmmercial driver must be able t perfrm all jb-related tasks, including lifting, t be certified. 6. Lungs and Chest Yu must examine the lungs and chest fr abnrmal chest wall expansin, respiratry rate, and breath sunds including wheezes r alvelar cngestin. Yu must check fr impaired respiratry functin and cyansis. Be sure t examine the extremities fr clubbing f the fingers and ther signs f pulmnary disease. Des yur examinatin detect a respiratry dysfunctin that in any way culd interfere with the ability f the driver t safely perate a CMV? The driver may need t have pulmnary functin tests and/r have a specialist evaluatin t adequately assess respiratry functin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 61

62 Bdy System (Clumn 2) CHECK FOR: 7. Abdmen and Viscera Yu must check fr enlarged liver and spleen, masses, bruits, hernia, and significant abdminal wall muscle weakness. Check fr tenderness. Des an abnrmal finding suggest a cnditin that might interfere with safe CMV peratin? 8. Vascular System Yu must check fr abnrmal pulse and amplitude, cartid r arterial bruits, and varicse veins. Check fr pedal pulses. The diagnsis f arterial disease shuld prmpt yu t evaluate fr the presence f ther cardivascular diseases. Adequate evaluatin may require additinal testing and/r specialist examinatin. 9. Geniturinary System Yu must check fr hernias. Yu shuld evaluate any hernia that causes the driver discmfrt t determine the extent t which the cnditin might interfere with the ability f the driver t perate a CMV safely. Obtain further testing and evaluatin as required. An abnrmal urinalysis indicates further testing t rule ut underlying medical prblems. NOTE: Yu cannt certify a driver wh has nt prvided a urine specimen. 10. Extremities-Limb Impaired. Driver may be subject t Skill Perfrmance Evaluatin (SPE) certificate if therwise qualified. Check fr fixed deficits f the extremities caused by lss, impairment, r defrmity f an arm, hand, finger, leg, ft, r te. Des the driver have a perceptible limp? Des the driver have sufficient grasp and prehensin in the upper limbs t maintain steering wheel grip? Des the driver have sufficient mbility and strength in lwer limbs t perate CMV pedals prperly? Des the driver have signs f prgressive musculskeletal cnditins, such as atrphy, weakness, r hyptnia? NOTE: If yu find a driver is medically qualified EXCEPT fr a fixed deficit f an extremity caused by the lss r functinal impairment f a limb, yu may qualify the driver, subject t btaining an SPE certificate. The SPE prgram is intended nly fr individuals with fixed deficits f the extremities (nt fr individuals with prgressive diseases). Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 62

63 11. Spine, Other Musculskeletal Yu must check the musculskeletal system fr previus surgery, defrmities, limitatins f mtin, and tenderness. Des the driver have a diagnsis r signs f a cnditin knwn t be assciated with acute episdes f transient muscle weakness, pr muscular crdinatin, abnrmal sensatins, decreased muscular tne, and/r pain? What is the: Nature and severity f the cnditin? Degree f limitatin present? Likelihd f prgressive limitatin? Likelihd f gradual r sudden incapacitatin? 12. Neurlgical Yu must examine the driver fr impaired equilibrium, crdinatin, and speech pattern. Des the driver have ataxia? Are deep tendn reflexes symmetric? Are patellar reflexes nrmal? Is the Babinski's reflex nrmal? Are there any sensry r psitinal abnrmalities? Des an abnrmal finding suggest a cnditin that might interfere with safe CMV peratin? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 63

64 Cardivascular 49 CFR (b)(4) Summary f regulatin "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n current clinical diagnsis f mycardial infarctin, angina pectris, crnary insufficiency, thrmbsis, r any ther cardivascular disease (CVD) f a variety knwn t be accmpanied by syncpe, dyspnea, cllapse, r cngestive cardiac failure." Relevance t Driving A fundamental questin when deciding if a cmmercial driver shuld be medically certified is whether the driver has a CVD that increases the risk f sudden death r incapacitatin and creates a danger t the safety and health f the driver, as well as the public sharing the rad. A number f cncerns beynd the typical cardiac risk factrs predispse cmmercial drivers t an increased risk f CVD: Accrding t the Cmmercial Driver s License Infrmatin System, in 2009 the average age f a driver is 39 years. Obesity and a sedentary lifestyle increase the risk f CVD. Bth are mre cmmn in the cmmercial driving ppulatin than in the general ppulatin. Driving stressrs, such as traffic cngestin, erratic shift wrk, a sense f respnsibility fr thers, and emtinal distress due t belligerent passengers, can lead t increased neursympathetic and adrencrtical catechlamine and crtisl release. This increases the likelihd f changes in arterial tne, mycardial excitability and cntractility, and thrmbgenic prpensity, particularly given the aging wrkfrce in the United States. Drivers are expsed t ther envirnmental stressrs that may be detrimental t the cardivascular system, such as excessive nise, temperature extremes, air pllutin, and whle bdy vibratin. The effect f CVD n the cmmercial driver is significant nw and will increase in the future. The majr clinical manifestatins f CVD are acute mycardial infarctin, angina pectris, sudden death, and cngestive heart failure. Arrhythmia is the mst likely cause f sudden driver incapacitatin. Hwever, crnary heart disease (CHD) is the mst cmmn etilgy. Estimated frequencies f initial presentatin f CHD are apprximately 50% acute mycardial infarctin, 30% angina, and 20% sudden death. Sudden cardiac dysfunctin is particularly relevant t safety-sensitive psitins, such as pilts, merchant marines, and cmmercial drivers. In these jbs, plicies are expected t prtect against gradual r sudden incapacitatin n the jb and harm t the public. The effect f heart disease n driving must be viewed in relatin t the general health f the driver. Other medical cnditins may exacerbate a cardivascular cnditin. Thus, medical certificatin t drive depends n a cmprehensive medical assessment f verall health and infrmed medical judgment abut the impact f single r multiple cnditins n the whle persn. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 64

65 Disqualificatin requires that the CMV driver exhibit a higher than acceptable likelihd f acute incapacitatin frm a cardiac event, resulting in an increased risk t the safety and health f the driver and the public. Key Pints fr Cardivascular Medical Examinatin Regulatins Des the driver have: A current clinical diagnsis f mycardial infarctin, angina pectris, crnary insufficiency, r thrmbsis? Syncpe, dyspnea, r cllapse? Heart failure? A histry f heart disease r acute mycardial infarctin? A histry f ther heart cnditins? A histry f heart surgery (valve replacement/bypass, angiplasty, implantable cardiac defibrillatr, pacemaker)? Use cardivascular medicatins that effectively cntrl a cnditin withut side effects that interfere with safe driving? Recmmendatins Questins yu may ask explre: Des the driver experience: Chest pain? Chest pressure r ache with exertin? Pain, pressure, r dyspnea at rest r with exertin? Recurrent and/r severe palpitatins? Pre-syncpe (dizziness, light-headedness) r true syncpe (lss f cnsciusness)? Medical therapy that requires mnitring? Regulatins: On examinatin, des the driver have: Murmurs, extra heart sunds, r arrhythmias? An enlarged heart? Abnrmal pulse r amplitude, cartid r arterial bruits, r varicse veins? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 65

66 Cardivascular Guidance/Advisry Criteria Aneurysms, Peripheral Vascular Disease, and Venus Disease and Treatments Cardiac Arrhythmias and Treatments Cardivascular Tests Cardivascular Recmmendatin Tables Only (PDF) Crnary Heart Diseases and Treatments Cngenital Heart Disease Heart Transplantatin High Bld Pressure/Hypertensin (b)(6) Mycardial Disease Syncpe Valvular Heart Diseases and Treatments The cmplete text f the medical cnference reprts can be accessed frm FMCSA Medical Reprts. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 66

67 Respiratry 49 CFR (b)(5) Summary f regulatin "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n established medical histry r clinical diagnsis f a respiratry dysfunctin likely t interfere with his/her ability t cntrl and drive a cmmercial mtr vehicle safely." Relevance t Driving The cmmercial driver spends mre time driving than the average individual. Driving is a repetitive and mntnus activity that demands the driver be alert at all times. Symptms f respiratry dysfunctin r disease can be debilitating and can interfere with the ability t remain attentive t driving cnditins and t perfrm heavy exertin. Even the slightest impairment in respiratry functin under emergency cnditins (when greater xygen supply may be necessary fr perfrmance) can be detrimental t safe driving. There are many primary and secndary respiratry cnditins that interfere with xygen exchange and may result in gradual r sudden incapacitatin, fr example: Asthma. Carcinma. Chrnic brnchitis. Emphysema. Obstructive sleep apnea. Tuberculsis. In additin, medicatins used t treat respiratry cnditins, bth prescriptin and thse available withut prescriptin, may cause cgnitive difficulties, cmpund the risk fr excessive daytime sleepiness (EDS), r cause r cntribute t ther frms f incapacitatin. Key Pints fr Respiratry Medical Examinatin Regulatins Des the driver experience r have: Shrtness f breath? Lung disease? Emphysema? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 67

68 Asthma? Chrnic brnchitis? Sleep disrder? Pauses in breathing while asleep? Daytime sleepiness? Lud snring? Recmmendatins Questins yu may cnsider Des the driver: Smke? If yes, hw much and fr hw lng? Feel shrt f breath while driving? Cugh frequently? If yes, is the cugh prductive f sputum? Experience tightness f the chest r shrtness f breath while resting r exercising? Wheeze during the day r night r with exertin? Use respiratry agents? Use xygen therapy? Self-reprt sleepiness that may indicate increased risk fr EDS? Regulatins Des the driver have: Impaired respiratry functin? Cyansis? Abnrmal: Chest wall expansin? Respiratry rate? Abnrmal breath sunds, including wheezes r alvelar cngestin? Findings that may require further testing such as pulmnary tests r referral? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 68

69 Recmmendatins Yu may request A detailed pulmnary functin evaluatin r cnsultatin with a pulmnlgist when the physical examinatin reveals: Clubbing f the fingers. Cyansis. Prlnged expiratin. Tachypnea at rest. Pulmnary wheezes and rhnchi, alvelar cngestin. Absent r decreased breath sunds. Pleural frictin rub. Unequal inflatin-deflatin cnturs f the right and left thrax. Significant kyphsis r sclisis f the thracic spine. Use f accessry muscles f ventilatin at rest. REMINDER: When requesting additinal evaluatin frm a specialist, the specialist must understand the rle and functin f a driver; therefre, it is helpful if yu include a cpy f the descriptin f the driver rle fund in the Examinatin Reprt frm and the applicable medical standard and guidelines. Respiratry Guidance/Advisry Criteria Allergies and Asthma-related Diseases Chrnic Obstructive Pulmnary Disease Chrnic Sleep Disrders Infectius Respiratry Diseases Nn-infectius Respiratry Diseases Pulmnary Functin Tests Secndary Respiratry Cnditins and Underlying Disrders The cmplete text f the medical cnference reprts can be accessed frm FMCSA Medical Reprts. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 69

70 Neurlgical 49 CFR (b)(8) Summary f regulatin "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn- Has n established medical histry r clinical diagnsis f epilepsy r any ther cnditin which is likely t cause lss f cnsciusness r any lss f ability t cntrl a cmmercial mtr vehicle." Relevance t Driving CMV drivers must be able t sustain vigilance and attentin fr extended perids in all types f traffic, rad, and weather cnditins. Neurlgical demands f driving include: Cgnitive demands: Sustained vigilance and attentin. Quick reactins. Cmmunicatin skills. Apprpriate behavir. Physical demands: Crdinatin. Risk frm Headaches Mst individuals have experienced symptms f headaches, vertig, and dizziness. While generally incnsequential, these symptms may cnstitute a prblem fr the driver f a CMV. Headache and chrnic "nagging" pain may be present t such a degree that certificatin fr driving a CMV is inadvisable and the medicatin used t treat headaches may further interfere with safe driving. Cmplaints shuld be thrughly examined when determining the verall fitness f the driver. Disrders with incapacitating symptms, even if peridic r in the early stages f disease, warrant the decisin t nt certify the driver. Risk frm Vertig and Dizziness Multiple cnditins may affect equilibrium r balance resulting in acute incapacitatin r varying degrees f chrnic spatial disrientatin. Types f vertig and dizziness with incapacitating symptms, even if peridic r in the early stages f disease warrant the decisin t nt certify the driver when symptms interfere with ne r mre f the fllwing: Cgnitive abilities. Judgment. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 70

71 Attentin. Cncentratin. Sensry r mtr functin. Risk frm Seizures and Epilepsy Safety is the majr reasn the driver with epilepsy r seizures is restricted frm cmmercial driving. Lss f cnsciusness endangers the driver and the public. The physical and mental demands f cmmercial driving expse seizure prne individuals t cnditins that may increase the risk fr seizures and may interfere with management f seizures, including: Incnsistent access t medical evaluatin and care f acute prblems. Delays in replacement f anticnvulsant medicatin if lst r frgtten. The length f time an individual is seizure free and ff anticnvulsant medicatin is cnsidered the best predictr f future risk fr seizures. Other cnsideratins include: The underlying cause f the seizure. The area f the brain affected by disease r injury. Many driver tasks, frm shifting t securing lads, require crdinated vluntary mvements. Yu shuld cnsider the fllwing safety implicatins when evaluating a driver: What is the nature and severity f the dysfunctin? What is the degree f limitatin? Is the limitatin likely t get wrse? Hw predictable is the degeneratin? What is the prbability f the dysfunctin happening withut warning versus prgressing ver the span f mnths r years? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 71

72 Key Pints fr Neurlgical Medical Examinatin Regulatins Des the driver have: Seizures, epilepsy, and/r use anticnvulsant medicatin? Histry f head/brain injuries, disrders, r illnesses? Episdes f lss f r altered cnsciusness? Episdes f fainting r dizziness? Histry f strke with residual impairment r paralysis? Spinal injury r disease with residual effects? Recmmendatins Questins yu may cnsider Des the driver have: Current limitatins resulting frm any neurmuscular, nervus, rganic, r functinal disrder? Symptms related t r caused by neurlgical diseases? Use medicatin t treat a neurlgical disrder, including: Anticnvulsants (anticnvulsant therapy recmmendatins). Anticagulants (anticagulant therapy recmmendatins). Antiplatelet drugs. Central nervus system stimulants and depressants. Des the histry f seizures include: Childhd febrile seizures? Prvked seizures (e.g., induced by anesthesia, hypglycemia, medicatins, r fever)? Unprvked seizures: Single episde? Tw r mre unprvked seizures (epilepsy)? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 72

73 Des the driver have signs f undiagnsed neurlgical disease? Cnsider: Is the drivers reprted infrmatin incrrect r incmplete? Are instructins fllwed and the respnses apprpriate and relevant? Is the appearance: Reasnable fr the situatin? Reflective f gd persnal hygiene? D questins and respnses demnstrate alertness, cmprehensin, apprpriateness, and relevance? Is behavir apprpriate t the neurlgical functining required t drive safely? Regulatins On examinatin, des the driver have: Cmprmised equilibrium, crdinatin, and/r impaired speech pattern? Asymmetrical deep tendn reflexes? Abnrmal patellar and Babinski reflexes? Sensry abnrmalities? Psitinal abnrmalities? Ataxia? Remember: Medical fitness-fr-duty includes the ability t perfrm strenuus labr. Medical fitness-fr -duty als requires the driver t be free f neurlgical limitatins that interfere with: Cgnitive abilities. Judgment. Attentin. Cncentratin. Visin. Physical strength. Agility. Reactin time. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 73

74 Neurlgical Guidance/Advisry Criteria Episdic Neurlgical Cnditins Infectins f the Central Nervus System Neurmuscular Diseases Prgressive Neurlgical Cnditins Static Neurlgical Cnditins Summary f Neurlgical Waiting Perids Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 74

75 Musculskeletal 49 CFR (b)(1)(2)(7) Summary f regulatin, 49 CFR (b)(1), 49 CFR (b)(2), 49 CFR (b)(7) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn b(1) Has n lss f a ft, a leg, a hand, r an arm, r has been granted a skill perfrmance evaluatin certificate pursuant t " b(2) "Has n impairment f: (i) A hand r finger which interferes with prehensin r pwer grasping; r (ii) An arm, ft, r leg which interferes with the ability t perfrm nrmal tasks assciated with perating a cmmercial mtr vehicle; r any ther significant limb defect r limitatin which interferes with the ability t perfrm nrmal tasks assciated with perating a cmmercial mtr vehicle; r has been granted a skill perfrmance evaluatin certificate pursuant t " b(7) "Has n established medical histry r clinical diagnsis f rheumatic, arthritic, rthpedic, muscular, neurmuscular, r vascular disease which interferes with his/her ability t cntrl and perate a cmmercial mtr vehicle safely." Relevance t Driving Disrders f the musculskeletal system affect driving ability and functinality necessary t perfrm heavy labr tasks assciated with the jb f cmmercial driving. Medical certificatin means the driver is physically able t safely drive and perfrm nn-driving tasks as described in the driver rle sectin f the FMCSA Examinatin Reprt frm. Drivers have a multitude f jb demands. The least physically demanding part may be the actual driving. Fr example, the duties f a cmmercial driver may include lading and unlading, making multiple stps, driving crss-cuntry and in heavy city traffic, wrking with lad securement devices, and changing tires. Other cmmn driving tasks include: Manipulating the wheel. Shifting gears. Maintaining pressure n the pedals. Braking. Mnitring traffic. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 75

76 Other jb tasks may include: Perfrming pre- and pst-trip safety checks. Ensuring the vehicle is laded prperly. Securing the lad. Evaluating and managing vehicle breakdwns. Respnding t emergency situatins. Key Pints fr Musculskeletal Medical Examinatin The ME shuld adapt the bservatin, inspectin, palpatin, and screening tests f the general musculskeletal examinatin t ensure that the physical demands f cmmercial driving are assessed (e.g., rtatin f the utstretched arms against resistance as if turning a large steering wheel, mvement f the legs in braking and clutching, etc.). The FMCSA Examinatin Reprt frm includes health histry questins. Additinal questins shuld be asked t supplement infrmatin requested n the frm. Any musculskeletal r neurmuscular cnditin shuld be evaluated fr the nature and severity f the cnditin, the degree f limitatin present, the likelihd f prgressive limitatin, and the ptential fr gradual r sudden incapacitatin. Regulatins Des the driver have: A muscular disease? A missing hand, arm, ft, leg, finger, r te? A nnfunctining r dysfunctinal hand, arm, ft, leg, finger, r te? An injury r disease f the spine? Chrnic lw back pain? Recmmendatins Questins yu may ask cnsider Des the driver: Have physical limitatins caused by weakness, pain, r decreased mbility and range f mtin? Use musculskeletal agents (effects and/r side effects)? Have mild, mderate, r severe chrnic musculskeletal pain (frequency and intensity)? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 76

77 Regulatins Des the driver have: A missing r impaired leg, ft, te, arm, hand, r finger? Sufficient pwer grasp and prehensin f hands and fingers t maintain steering wheel grip? Sufficient strength and mbility in lwer limbs t perate CMV pedals prperly? A perceptible limp? Signs f previus spine r ther musculskeletal surgery? Defrmities f the spine and/r trs? Sufficient mbility and strength f spine and/r trs t drive safely and perfrm ther jb tasks? Limitatins f mtin f the spine and/r trs? Spine, trs, and/r ther musculskeletal tenderness? NOTE: As a ME yu determine if the severity f a reversible r prgressive musculskeletal disease interferes with driving ability. If findings s dictate, radilgy and ther examinatins shuld be used t diagnse defects and musculskeletal abnrmalities. Examinatin by an rthpedist r physiatrist wh understands the functins and demands f cmmercial driving may be advisable t assess the status f the disease and is required in the case f an applicatin fr SPE. Remember, as a medical examiner, it is yur respnsibility t determine certificatin status. Musculskeletal Guidance/Advisry Criteria Skill Perfrmance Evaluatin 49 CFR Musculskeletal Tests Neurmuscular Diseases Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 77

78 Diabetes Mellitus (DM) 49 CFR (b)(3) Summary f regulatin, 49 CFR (b)(3) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n established medical histry r clinical diagnsis f diabetes mellitus currently requiring insulin fr cntrl." Relevance t Driving The Center fr Disease Cntrl and Preventin (CDC) 2007 Natinal Diabetes Fact Sheet reprts the prevalence f diagnsed and undiagnsed DM in the United States, fr all ages, as: Ttal: 23.6 millin peple, r 7.8% f the ppulatin, have DM. Diagnsed: 17.9 millin peple. Undiagnsed: 5.7 millin peple. The mst cmmn frm f DM is Type 2 (adult nset r nn-insulin-dependent DM). Individuals with Type 2 DM: Can prduce insulin and have intact bld glucse cntrl cunter-regulatry mechanisms. May preserve bld glucse cntrl cunter-regulatry mechanisms fr many years with lifestyle changes and ral hypglycemic medicatins. May, ver time, have insulin prductin fail and require insulin replacement therapy. While detectin and management f hyperglycemia and hypglycemia are imprtant aspects f the verall medical management f a persn with DM, the detectin and management f hypglycemia is mre relevant t safety cnsideratins, in the certificatin f the CMV driver, with DM. Factrs related t cmmercial driving that affect bld glucse cntrl include: Fatigue. Lack f sleep. Pr diet. Missed meals. Emtinal cnditins. Stress. Cncmitant illness. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 78

79 These same factrs may hasten the need fr the driver with DM wh des nt use insulin t start insulin therapy. Prly cntrlled DM can result in serius, life-threatening health cnsequences. Hwever, with gd management f the disease prcess, a driver with DM can safely perate a CMV. Hyperglycemia Risk Pr bld glucse cntrl can lead t fatigue, lethargy, and sluggishness. Cmplicatins related t acute hyperglycemia may affect the ability f a driver t perate a mtr vehicle. Althugh ketacidsis and hypersmlar states significantly impair cgnitive functin. Onset is gradual and frequency is generally lw. The cmplicatins f DM can lead t medical cnditins severe enugh t be disqualifying, such as neurpathy, retinpathy, and nephrpathy. Accelerated athersclersis is a majr cmplicatin f DM invlving the crnary, cerebral, and peripheral vessels. Individuals with DM are at increased risk fr crnary heart disease and have a higher incidence f painless mycardial infarctin than individuals wh d nt have DM. Hypglycemia Risk Preventing hypglycemia is the mst critical and challenging safety issue fr any driver with DM. Hypglycemia can ccur in individuals with DM wh bth use and d nt use insulin. Mild hypglycemia causes rapid heart rate, sweating, weakness, and hunger. Severe hypglycemia can cause symptms that interfere with safe driving. The FMCSA defines a severe hypglycemic reactin as ne that results in: Seizure. Lss f cnsciusness. Need f assistance frm anther persn. Perid f impaired cgnitive functin that ccurred withut warning. The ccurrence f a severe hypglycemic reactin while driving endangers the safety and health f the driver and the public. Key Pints fr Diabetes Mellitus Medical Examinatin Medical qualificatin f the driver with DM shuld be determined thrugh a case-by-case evaluatin f the ability f the driver t manage the disease and meet qualificatin standards. The FMCSA Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins abut DM symptms, treatment, and driver adjustment t living with a chrnic cnditin shuld be asked t supplement infrmatin requested n the frm. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 79

80 Regulatins Des the driver have DM r elevated bld glucse cntrlled by: Diet? Pills? Insulin? Other injectable medicatins? Recmmendatins Questins yu may cnsider Des the driver: Rutinely mnitr bld glucse level? Use ver-the-cunter medicatins and/r supplements? Use an incretin mimetic? Have a histry f fainting, dizziness, r lss f cnsciusness? Have a histry f hypglycemic reactins that resulted in: Seizure? Lss f cnsciusness? Need f assistance frm anther persn? Perid f impaired cgnitive functin that ccurred withut warning? NOTE: When the driver has a psitive histry fr severe hypglycemic reactins, ask abut ccurrences: One r mre ccurrences within last 12 mnths? Tw r mre ccurrences within last 5 years? Regulatins On examinatin, des the driver have: Glycsuria (dip stick urinalysis)? Signs f target rgan damage assciated with dysfunctin f the senses, including: Retinpathy? Macular degeneratin? Peripheral neurpathy? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 80

81 Signs f target rgan damage that can cause gradual r sudden incapacitatin, including: Crnary heart disease? Cerebrvascular disease, including: Transient ischemic attack? Emblic r thrmbtic strke? Peripheral vascular disease? Autnmic neurpathy? Nephrpathy? Remember The diabetes qualificatin standard parameter is use f insulin, nt the diagnsis f diabetes mellitus. Diabetes Mellitus Guidance/Advisry Criteria Use the fllwing links t select diabetes mellitus guidance/advisry criteria key pints: Diabetes Mellitus Tpics Diabetes Mellitus Incretin Mimetic Therapy Insulin Therapy Oral Hypglycemics Federal Diabetes Exemptin Prgram Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 81

82 Other Diseases 49 CRF (b)(9) Summary f regulatin, 49 CFR (b)(9) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n mental, nervus, rganic, r functinal disease r psychiatric disrder likely t interfere with his/her ability t drive a cmmercial mtr vehicle safely." Disrders f the geniturinary and gastrintestinal systems have nt been widely assciated with significant impact n driving ability fr drivers as a grup but may, n a case-by-case basis, interfere with safe driving. Yu shuld nt certify the driver until the etilgy is cnfirmed, and treatment has been shwn t be adequate/effective, safe, and stable. Regulatins Des the driver have: Any illness r injury in the last 5 years? Kidney disease, dialysis treatment? Liver disease? Digestive prblems? Regulatins On examinatin, des the driver have: Abnrmal urinalysis? Enlarged liver r kidney? Enlarged spleen? Masses? Bruits? Hernia? Other Diseases Guidance/Advisry Criteria Other Diseases/Tpics Nephrpathy Hernia Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 82

83 Psychlgical 49 CFR (b)(9) Summary f regulatin, 49 CFR (b)(9) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n mental, nervus, rganic, r functinal disease r psychiatric disrder likely t interfere with his/her ability t drive a cmmercial mtr vehicle safely." Relevance t Driving A fundamental questin when deciding if a cmmercial driver shuld be certified is whether the driver has a cnditin that increases the risk f sudden death r incapacitatin s that the cnditin creates a danger t the safety and health f the driver, as well as t the public sharing the rad. The qualificatin standards cver 13 areas that directly relate t the driving functin; hwever, n a case-by-case basis, the ME may use their clinical skills and knwledge f the FMCSA physical qualificatin standards t evaluate the verall medical fitness fr duty f the driver. ME s are expected t assess the nature and severity f medical cnditins and determine certificatin utcmes n a case-by-case basis with knwledge f the demands f cmmercial driving. "Emtinal r adjustment prblems cntribute directly t an individual s level f memry, reasning, attentin, and judgment. These prblems ften underlie physical disrders." "A variety f functinal disrders can cause drwsiness, dizziness, cnfusin, weakness, r paralysis that may lead t incrdinatin, inattentin, lss f functinal cntrl, and susceptibility t crashes while driving." "Physical fatigue, headache, impaired crdinatin, recurring physical ailments, and chrnic nagging pain may be present t such a degree that certificatin fr cmmercial driving is inadvisable." Disrders f the geniturinary and gastrintestinal systems have nt been widely assciated with significant impact n driving ability fr drivers as a grup but may, n a case-by-case basis, interfere with safe driving. Yu shuld nt certify the driver until the etilgy is cnfirmed, and treatment has been shwn t be adequate/effective, safe, and stable. Safe and effective peratin f a CMV requires high levels f physical strength, skill, and crdinatin as well as the ability t maintain adequate attentin and react prmptly and apprpriately t traffic, emergency situatins, and ther jb-related stressrs. Sme psychlgical r persnality disrders can directly affect memry, reasning, attentin, and judgment. Smatic and psychsmatic cmplaints shuld be thrughly examined when determining verall fitness t drive. Disrders f a peridically incapacitating nature, even in the early stages f develpment, may warrant disqualificatin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 83

84 Risk factrs assciated with persnality disrders can interfere with driving ability by cmprmising: Attentin, cncentratin, r memry affecting infrmatin prcessing and the ability t remain vigilant t the surrunding traffic and envirnment. Visual-spatial functin (e.g., mtr respnse latency). Impulse cntrl, including the degree f risk taking. Judgment, including the ability t predict and anticipate. Ability t prblem slve (i.e., executive functining), including the ability t respnd t simultaneus stimuli in a changing envirnment when ptentially dangerus situatins culd exist. The driver with: Active psychtic disrder may exhibit unpredictable behavir and pr judgment. Md disrder may, during a Manic episde exhibit grandisity, impulsiveness, irritability, and aggressiveness. Depressive episde exhibit slwed reactin time and pr judgment. Persnality disrders, depending n severity and type, may exhibit inflexible and maladaptive behavirs. Key Pints fr Psychlgical Examinatin Yu may ask abut psychlgical symptms and screening tests when indicated by the driver's affect, behavir, r yur interactins with the driver. It is the degree f inapprpriateness and the cumulative effect f driver presentatin and interactin that prvide a cue that a driver may require a mre in-depth mental health evaluatin. Regulatins Des the driver: Have a nervus r psychiatric disrder (e.g., severe depressin)? Have lss f r altered cnsciusness? Use medicatin fr a nervus r psychiatric disrder? Use alchl regularly and/r frequently? Use narctic r habit-frming drugs? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 84

85 Recmmendatins Des the driver display any f the fllwing: Inapprpriate dress? Suspiciusness? Evasiveness? Threatening behavir? Hstility? Distractibility? Flat affect r lack f emtinal expressin? Unusual r bizarre ideas? Auditry r visual hallucinatins? Dishnesty? Omissin f imprtant infrmatin? Recmmendatins Questins yu may cnsider: Have yu ever thught f hurting yurself? Have yu ever thught f suicide? Have yu attempted suicide, including using a vehicle like a car r truck? D yu ever get int fights? Have yu ever thught f hurting r killing ther peple? D yu ever have prblems with yur cncentratin r memry? Have yu ever heard vices that ther peple dn't hear r that weren't really there? Have yu ever seen things that weren't really there? Have yu ever been hspitalized fr psychiatric prblems? Are yu taking any medicatin fr nerves? Have yu ever used medicines fr a purpse ther than what was prescribed? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 85

86 Recmmendatins In additin t health histry, yu may inquire abut Wrk histry. Driving histry. Drug and alchl histry. Military histry, including type f discharge. Legal histry. Regulatins On examinatin, des the driver have: Inapprpriate affect Cgnitive deficits Tremr? Enlarged liver and/r spleen? Signs f alchlism r prblem drinking? Signs f drug abuse? Psychlgical Guidance/Advisry Criteria There are three categries f risk assciated with psychlgical disrders. The mental disrder, including symptms and/r disturbances in perfrmance that are an integral part f the disrder and may pse hazards fr driving. Residual symptms ccurring after time-limited reversible episdes r initial presentatin f the full syndrme that can interfere with safe CMV driving. Psychpharmaclgy, as many psychtrpic medicatins can cmprmise perfrmance t the degree that CMV driving wuld be hazardus. The recmmendatins d nt supprt autmatic exclusin frm CMV driving based slely n the diagnsis. Typically, the mre serius the diagnsis, the mre likely it is that the driver will be medically disqualified. Careful cnsideratin shuld als be given t the side effects and interactins f medicatins in the verall qualificatin determinatin. Many f the medicatins used t treat psychlgical disrders have effects and/r side effects that render driving unsafe. The recmmendatins use the degree f impairment prduced by a 0.04 percent bld alchl cncentratin as a benchmark. This standard was chsen based n the FMCSA exclusinary rule related t alchl usage. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 86

87 Psychlgical Guidance/Advisry Criteria Adult Attentin Deficit Hyperactivity Disrder Biplar Md Disrder Majr Depressin Persnality Disrders Schizphrenia and Related Psychtic Disrders Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 87

88 Part IV Drug & Alchl Usage Disqualifying/Qualifying Medicatins & Medical Exemptins Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 88

89 Medicatins, Drug Abuse and Alchlism 49 CFR (b)(12)(i)(13) Summary f regulatin, 49 CFR (b)(12)i)(ii)(A)(B), 49 CFR (b)(13) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn b(12)(i) Des nt use a cntrlled substance identified in 21 CFR Schedule I, an amphetamine, a narctic, r any ther habit-frming drug. Exceptin. A driver may use such a substance r drug, if the substance r drug is prescribed by a licensed medical practitiner wh: Is familiar with the driver s medical histry and assigned duties; and Has advised the driver that the prescribed substance r drug will nt adversely affect the driver s ability t safely perate a cmmercial mtr vehicle." b(13) "Has n current clinical diagnsis f alchlism." Relevance t Driving There is verwhelming evidence that drug and alchl use and/r abuse interferes with driving ability. Althugh there are separate standards fr alchlism and ther drug prblems, in reality much substance abuse is ply-substance abuse, especially amng persns with antiscial and sme persnality disrders. Alchl and ther drugs cause impairment thrugh bth intxicatin and withdrawal. Episdic abuse f substances by cmmercial drivers that ccurs utside f driving perids may still cause impairment during withdrawal. Hwever, when in remissin, alchlism is nt disabling unless transient r permanent neurlgical changes have ccurred. Alchl and ther drug dependencies and abuse are prfund risk factrs assciated with persnality disrders that interfere with safe driving. Even in the absence f abuse, the cmmercial driver shuld be made aware f ptential effects n driving ability resulting frm the interactins f drugs with ther prescriptin and nnprescriptin drugs and alchl. The Office f Drug & Alchl Plicy & Cmpliance versees intermdal (e.g., Federal Mtr Carrier Safety Administratin (FMCSA), Federal Railrad Administratin, Federal Transit Administratin, and Federal Aviatin Administratin) drug and alchl testing prgrams in accrdance with the Omnibus Transprtatin Emplyee Testing Act f See the FMCSA Drug and Alchl Prgram Web page fr mre infrmatin abut the regulatins and guidelines gverning CMV drivers. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 89

90 The effects and/r side effects f medicatins may interfere with safe driving. The driver may experience an altered state f alertness, attentin, r even temprary cnfusin. Other medicatins may cause physical symptms such as hyptensin, sedatin, r increased bleeding that can interfere with task perfrmance r put the driver at risk fr gradual r sudden incapacitatin. Cmbinatins f medicatins and/r supplements may have synergistic effects that ptentiate side effects, causing gradual r sudden incapacitatin. The demands f cmmercial driving may cmplicate adherence t prescribed dsing intervals and precautins. Irregular meal timing, perids f sleep deprivatin r pr sleep quality, and irregular r extended wrk hurs can alter the effects f medicine and cntribute t missed r irregular dsing. Physical demands may increase pain and the need fr medicatin use. Three types f medicatins may be used by the cmmercial driver: Prescriptin. Over-the-cunter (OTC). Supplements and herbs. Every year, mre medicatins are available withut prescriptin and prvider supervisin. Nnprescriptin medicatins are nt necessarily safe t use while driving. In the advisry criteria general infrmatin, ME s are instructed t discuss cmmn prescriptins and OTC medicatins relative t the side effects and hazards f these medicatins while driving. In additin, ME s shuld advise the CMV driver t read and adhere t warning labels n all medicatins. General Purpse f Health Histry and Physical Examinatin As a ME yur fundamental bligatin is t medically evaluate a driver t ensure that the driver has n medical cnditin that interferes with the safe perfrmance f driving tasks n a public rad. If a driver has a current drinking prblem, clinical alchlism, uses a Schedule I drug r ther substance such as an amphetamine, a narctic, r any ther habit-frming drug, the effects and/r side effects may interfere with driving perfrmance, thus endangering public safety. During the physical examinatin, yu shuld ask the driver t prvide a cmplete histry f medicatin use, including OTC medicatins and herbal supplements. The FMCSA Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins shuld be asked t supplement infrmatin requested n the frm. Yu may ask questins t ascertain the level f knwledge regarding apprpriate use f medicatins while driving. Key Pints fr Medical Assessment fr Drug Abuse and/r Alchlism Yu may use drug and/r alchl abuse screening tests. NOTE: A test fr cntrlled substances is nt required as part f the medical certificatin prcess. The FMCSA r the emplyer shuld be cntacted directly fr infrmatin n cntrlled substances and alchl testing under Part 382 f the FMCSRs. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 90

91 Regulatins Des the driver use: Alchl, regularly and frequently? Narctic r habit-frming drugs? Des the driver use medicatins t: Treat cardivascular disease? Reduce hypertensin? Cntrl bld glucse level? Oral hypglycemics? Insulin? Cntrl seizures r treat epilepsy? Treat nervus r psychiatric disrders? Did the driver list all medicatins (including OTC medicatins) used regularly r recently? Recmmendatins Questins that yu may cnsider Des the driver wh uses alchl: Have a cnsumptin pattern that indicates additinal evaluatin may be needed based n quantity per ccasin r per day/week? Pass standardized screening questins (e.g., Alchl Use Disrders Identificatin Test (AUDIT), CAGE, and T-ACE)? Have a histry f driver and/r family alchl-related medical and/r behaviral prblems? Des the driver wh uses narctic r habit-frming drugs have a: Therapeutic r habitual need? Gal t alter md, affect, r state f cnsciusness? Gal t extend physical limits by use f stimulants? Histry f drug rehabilitatin? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 91

92 NOTE: Certificatin may require successful cmpletin f a substance abuse prfessinal (SAP)- required drug rehabilitatin prgram. Participatin in a self-help prgram cannt be substituted fr cmpletin f a SAP-required drug rehabilitatin prgram. Vluntary, nging participatin in a self-help prgram t supprt recvery is nt disqualifying. Recmmendatins Questins that yu may ask: Des the driver experience: Dizziness r light-headedness? Hypertensin? Sedatin? Depressed md? Cgnitive deficit? Decreased reflex respnses? Unsteadiness? Regulatins On examinatin, des the driver have signs f alchlism, prblem drinking, r drug abuse, including: Tremr. Enlarged liver. On examinatin and evaluatin, des the taken medicatin have: The desired effect n the underlying disease (e.g., bld pressure is lwered)? Side effects that interfere with safe driving (e.g., uncntrllable tremr r rthstatic hypertensin)? Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 92

93 Imprtant cnsideratins fr medicatin use while driving Des the medicatin: Indicate the presence f an underlying disqualifying disease r injury? Effectively treat the disease r medical cnditin? Exhibit side effects that interfere with safe driving? Have side effects that interfere with lifestyle functins such that the driver may cease t cmply with treatment. Have ptential fr gradual r sudden incapacitatin, r exacerbatin f underlying medical cnditin, due t missed dse (e.g., seizure, psychsis)? Require mnitring t maintain a therapeutic dse r prevent txicity (e.g., Cumadin)? Interact with ther drugs, fd, and/r alchl, interfering with the ability t drive? Des the driver: Understand and cmply with the medicatin plan, including mnitring? Knw what warning signs might indicate medicatin txicity, interactin, etc.? Stre medicatins prperly when driving lng haul r crss cuntry? Read and understand warning labels n medicatins and supplements? Cnsult the treating healthcare prfessinal and/r a pharmacist befre using a new medicatin r cmbining medicatins while driving. Medicatin, Drug Abuse and Alchlism Guidance/Advisry Criteria Alchlism Drug Abuse Drug and Alchl Prgram Abut 49 CFR Part 382 Cntrlled Substances and Alchl Use and Testing Abut 21 USC Sec. 812 Schedules f Cntrlled Substances Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 93

94 Part V Additinal Testing & Evaluatin Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 94

95 Additinal Testing and Evaluatin The FMCSA CMV driver examinatin diagnstic testing requirements are: a. Urine test fr specific gravity, prtein, bld and glucse ( (a)(3)(i)); b. Whisper r audimetric testing ( (b)(11)); c. Visin testing fr clr visin, distant acuity, hrizntal field f visin ( (b)(10)); d. Bld pressure and pulse ( (b)(6); Hwever, the ME shuld cnsider the need fr additinal testing and cnsultatin when indicated t determine the driver s medical and physical cnditin. Remember: When requesting additinal evaluatin frm a specialist, the specialist must understand the rle and functin f a driver; therefre, it is helpful if yu include a cpy f the descriptin f the driver rle fund in the Examinatin Reprt frm and the applicable medical standard and guidelines. Remember: 13 certificatin standards are used t determine medical fitness fr duty. Fur standards are bjective: visin, hearing, epilepsy and insulin dependent DM. The ther nine discretinary standards rely f the ME s clinical judgment fr determinatin f fitness fr duty. Remember: When a CMV driver is under the care f a practitiner (particularly a specialist) the ME shuld cnsider incrprating the clinician s pinin and endrsement f the driver s qualificatins t safely perfrm CMV driving tasks and duties. Remember: The ME can always certify fr a perid f time less than the 2 year maximum and the ME can always temprarily disqualify a CMV driver t seek further infrmatin r await imprvement in a temprary medical cnditin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 95

96 Remember: When the ME is unsure f certificatin f a CMV driver, it is the ME s respnsibility t seek further clinical infrmatin. In ther wrds, if it desn t smell right dn t apprve. If unsure dn t apprve. Remember: Yu are never required t certify a driver fr a certificatin interval lnger than what yu deem necessary t adequately mnitr driver medical fitness fr duty. Remember: Medical fitness fr duty includes the ability t prefrm strenuus labr. Overall requirements fr cmmercial drivers as well as the specific requirements in the jb descriptin f the driver shuld be the deciding factrs in the certificatin prcess. The ME shuld cnsider specialist referral/cnsultatin fr CMV drivers wh exhibit evidence f any f the fllwing disrders ( (e) and (f)): visin (e.g., retinpathy, macular degeneratin); cardiac (e.g., mycardial infarctin, crnary insufficiency, bld pressure cntrl); pulmnary (e.g., emphysema, fibrsis, bstructive sleep apnea); endcrine (e.g., diabetes); musculskeletal (e.g., neurmuscular disease); mental / emtinal health (e.g., depressin, schizphrenia); r ther medical cnditin(s) that may interfere with ability t safely perate a CMV Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 96

97 Part VI Driver Health Cunseling Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 97

98 Driver Health Cunseling The ME shuld infrm and educate the CMV driver abut nn-disqualifying medical cnditins that require remedial care. The cunseling shuld address: a. Cnsequences f nn-cmpliance with a care plan fr cnditins that have been advised fr peridic mnitring with primary healthcare prvider; b. Side effects and interactins f medicatins (e.g., narctics, anticagulants, psychtrpics) including prducts acquired ver-the-cunter (e.g., antihistamines, cld and cugh medicatins r dietary supplements) that culd negatively affect driving; c. The effect f fatigue, lack f sleep, pr diet, emtinal cnditins, stress, and ther illnesses that can affect safe driving; d. If driver is a cntact lens user, the imprtance f carrying a pair f glasses while driving; e. If driver uses a hearing aid, the imprtance f carrying a spare pwer surce fr the device while driving; f. If driver has a histry f deep vein thrmbsis, the risk assciated with inactivity while driving and interventins that culd prevent anther thrmbtic event; g. If driver has a diabetes exemptin, that he/she shuld: carry a rapidly absrbable frm f glucse while driving; self-mnitr bld glucse ne hur befre driving and at least nce every fur hurs while driving; cmply with each cnditin f his/her exemptin; plan t submit glucse mnitring lgs fr each annual recertificatin; h. Crrective r therapeutic steps needed fr cnditins which may prgress and adversely impact safe driving ability (e.g., seek fllw-up frm primary care physician); i. Steps needed fr recnsideratin f medical certificatin if driver is certified with a limited interval, e.g., the return date and dcumentatin required fr extending the certificatin time perid. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 98

99 Part VII Driver Qualificatin/Disqualificatin Dispsitin Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 99

100 Examinatin Reprt Frm Determining Certificatin Status The FMCSA relies n the ME t assess and determine if the CMV driver meets the physical qualificatin requirements cited in 49 CFR In sme cases, ME s will als cnsider reprts and recmmendatins frm the primary care prvider and/r specialists treating r evaluating the driver t supplement the examinatin and ensure adequate medical assessment. As a ME, yu are respnsible fr determining the certificatin decisin and signing the Examinatin Reprt frm and issuing an Examiner's Certificate t the CMV drivers determined t be medically fit fr duty. The certificatin decisin is limited t the certificatin and disqualificatin ptins printed n the Examinatin Reprt frm. The maximum time a driver can be certified is 2 years. ME s can, hwever, certify fr a perid f time less than 2 years. Certificatin Status When ME s determine that a driver is medically fit t drive and able t perfrm the nn-driving respnsibilities and duties, they are t certify the driver and issue an Examiner's Certificate. When the ME determines that a driver has a health histry r cnditin that des nt meet physical qualificatin standards, they must nt certify the driver. Hwever, ME s shuld cmplete the examinatin t determine if the driver has mre than ne disqualifying cnditin. Sme cnditins are reversible, and the CMV driver may take actins that will enable him/her t meet qualificatin requirements with successful treatment. Discussin Regarding Certificatin Decisin Yu must discuss yur certificatin decisin with the driver. Ensure that the driver understands the certificatin decisin and any: Reasn fr peridic mnitring and shrtened examinatin interval. Additinal requirements assciated with certificatin. Examiner's Certificate expiratin infrmatin. Reasn fr disqualificatin. Steps that can be taken t meet certificatin standards. Temprary disqualificatin. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 100

101 Reasn (cnditin r medicatin). Length f waiting perid. Cnditins that culd restart the waiting perid. List f any dcumentatin the driver is t prvide t the medical examiner. NOTE: A driver is certified frm the date f examinatin. If nly the disqualifying cnditin, e.g., bld pressure, is evaluated at the next examinatin fllwing temprary disqualificatin, the date f the initial examinatin is used t calculate the certificatin perid. If the examiner perfrms a cmplete physical examinatin, then the certificatin perid is calculated frm the date f this examinatin. Regulatins Yu must dcument the driver physical examinatin Yu must recrd the results f every driver physical examinatin, in accrdance with the Examinatin Reprt frm and the instructins cited in 49 CFR Examinatin Reprt Frm ME s shall retain the driver medical recrds fr a minimum f 3 years. ME s will need t prvide a cpy f the Examinatin Reprt frm t a driver wh is applying fr, r renewing a: Skill Perfrmance Evaluatin (SPE) certificate. Diabetes exemptin certificate. Visin exemptin certificate. Examiner's Certificate ME s shall prvide the riginal t the driver yu examined and fund medically fit fr duty. A cpy f the driver medical recrds, including the certificate, must be retained fr 3 years. ME s may prvide a cpies f driver medical recrds t a prspective r current emplyer upn request. The CMV driver must carry the Examiner's Certificate while perating a CMV. The certificate may be: The riginal certificate. A cpy f the riginal certificate. A reduced-size cpy f the riginal certificate (e.g., wallet size). Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 101

102 Examinatin Reprt Frm Certify As a ME, yu determine when a driver meets physical qualificatin requirements. The nly requirements yu can stipulate when certifying a driver are thse in the "Nte certificatin status here" sectin f Examinatin Reprt frm and n the Examiner's Certificate. Yu als determine when the driver must repeat the physical examinatin fr cntinuus certificatin. Althugh the ME cannt exceed the maximum certificatin perid, ME s are never required t certify a driver fr a certificatin interval lnger than deemed necessary t adequately mnitr driver medical fitness fr duty. Certify Determine Certificatin Interval Overview Regulatins Maximum certificatin 2 years Qualify fr 2-Year Certificate Mark the Meets standards in 49 CFR ; qualifies fr 2 year certificate bx. Verify that the expiratin date is 2 years frm the date f the physical examinatin. Qualify With Peridic Mnitring (less than 2 years) Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 102

103 Sme FMCSA medical guidelines include recmmendatins fr maximum certificatin intervals 1 year r less. Recmmended maximum certificatin perids are cnsidered best practices. Mark the Meets standards, but peridic mnitring required due t bx. Nte the reasn fr peridic mnitring. Indicate the length f certificatin by checking 3 r 6 mnths, 1 year, r Other and write in the time frame (e.g., 1 mnth). Calculate the expiratin date frm the date f the initial physical examinatin, nt a fllw-up examinatin date. As a ME, yu must specify, as a requirement fr certificatin, that a driver wear crrective lenses and/r a hearing aid when applicable. Qualify Skill Perfrmance Evaluatin (SPE) Certificate Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 103

104 By marking the SPE ptin, yu certify that the driver: Fails t meet the limb requirements f 49 CFR (b)(1) r (2). Meets all ther physical requirements cited in 49 CFR (b). Must have bth a valid SPE certificate and ME's Certificate t drive. As a ME, yu start the SPE prgram applicatin prcess by first determining if the driver is therwise medically qualified. The SPE certificate is issued fr 2 years. A cpy f the Examinatin Reprt frm is required with initial and renewal SPE applicatins. Certify Require Driver T Have a Federal Exemptin Regulatins Maximum certificatin 1 year Qualify With a Federal Exemptin There are tw Federal medical exemptin prgrams fr drivers: The Diabetes Exemptin Prgram allws sme drivers with diabetes mellitus wh use insulin replacement therapy t drive a CMV. The Visin Exemptin Prgram allws sme drivers with mncular visin t drive a CMV. As a ME, yu start the exemptin prgram applicatin prcess by first determining if the driver is therwise medically qualified except fr mncular visin r the use f insulin. A cpy f the Examinatin Reprt frm is required with bth the initial and renewal Federal exemptin applicatins. By marking Accmpanied by a waiver/exemptin, circling "exemptin," and writing in the Federal prgram name, yu certify that the driver: Fails t meet the insulin use requirement f 49 CFR (b)(3) r the mncular visin requirement f 49 CFR (b)(10). Meets all ther physical requirements cited in 49 CFR (b). Must als have a valid Federal medical exemptin certificate t drive. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 104

105 Qualify By Operatin f 49 CFR Applies t a small number f individuals wh participated in the FMCSA studies cnducted prir t the implementatin f the medical exemptin prgrams. By checking the By Operatin f 49 CFR , ptin, yu certify that the driver: Presented dcumentatin f participatin in a study. Cntinues t meet 49 CFR requirements. Is therwise medically fit fr duty. Qualify Driving Within an Exempt Intracity Zne Intracity znes are gegraphical areas defined in the regulatins. By checking the Driving within an exempt intracity zne (See 49 CFR ) ptin, yu certify that the driver: Is therwise medically fit fr duty except fr the exempted cnditin. The exempted cnditin remains stable. Remains in medical cmpliance with the requirements f sectin Examinatin Reprt Frm Disqualify As a ME, yu must disqualify the driver wh des nt meet ne r mre f 49 CFR physical qualificatin standards. Yu shuld cmplete the physical examinatin f the driver and discuss with him/her the reasn(s) fr disqualificatin and any steps that can be taken t meet certificatin standards. Disqualify Discuss and Dcument Decisin Regulatins Disqualify driver wh des nt meet standards As a medical examiner, yu must disqualify the driver wh: Fails t meet a physical qualificatin requirement cited in the standards (e.g., visin test result, hearing lss test result, epilepsy, r insulin use). Yu believe has a medical cnditin that endangers the health and safety f the driver and the public. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 105

106 Dcument the decisin t disqualify n the Examinatin Reprt frm. Mark the "Des nt meet standards" bx. Nte the reasn fr disqualificatin. Dcument the discussin with the driver explaining the ratinale fr the decisin t disqualify. NOTE: DO NOT issue an Examiner's Certificate. Disqualify Temprarily When the disqualifying cnditin r treatment has a clinical curse likely t restre driver medical fitness fr duty, yu may cmplete the: Temprarily disqualified due t (cnditin r medicatin): line. Return t medical examiner's ffice fr fllw up n line. When a recmmended waiting perid is applicable, the date: Shuld be greater than r equal t the waiting perid. Shuld be greater than r equal t the lngest waiting perid when the driver has multiple medical cnditins. NOTE: DO NOT issue an Examiner's Certificate. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 106

107 REMEMBER The driver is disqualified and nt allwed t perate a CMV until a ME finds the driver t be medically fit fr duty. Examiner s Certificate Regulatins ME issues certificate t medically qualified driver When a ME finds that the driver examined is medically qualified t perate a CMV in accrdance with 49 CFR (b), the ME shuld cmplete a certificate as prescribed in 49 CFR (h) and furnish the riginal t the CMV driver wh was examined. The ME may prvide a cpy t a prspective r current emplyer requesting ne. Surce Federal Mtr Carrier Safety Administratin Department f Transprtatin 107