Missouri Skill Performance Evaluation Certificates

Transcription

1 Missouri Skill Performance Evaluation Certificates For Intrastate Drivers Missouri allows individuals who are not physically qualified to drive commercial motor vehicles intrastate because of one or more of the following conditions, to apply for a Skill Performance Evaluation certificate: Limb amputation Limb impairment Vision impairment Insulin treated diabetes mellitus If the application is approved, the driver is authorized to haul in intrastate commerce that is, the vehicle and its load must originate and end within Missouri s borders only. Is the Missouri SPE certificate the same as the federal SPE certificate? No. The Missouri certificate qualifies drivers to operate only within Missouri borders. The federal SPE certificate program is for interstate drivers and applies only to limb impaired and amputee drivers. Drivers with vision impairments or diabetes can apply for a federal medical exemption to operate interstate. Can I apply for an SPE certificate on my own or do I need a sponsor? Applications can be filed by an individual driver or jointly by the driver and a sponsoring employer. What is involved in the SPE process? Applicants must complete an application and provide required documents. In limb impaired/amputation cases, a skill evaluation must be performed. Vision and diabetes exemptions are submitted for public comment before a decision is made. I already have a federal SPE certificate or medical exemption. Now I want to drive in Missouri only. Can I? You must apply for a Missouri SPE certificate, but some application requirements can be waived if your federal certificate or exemption is still valid. How long does the Missouri SPE certificate application process take? Once your completed application is received, the process normally is completed within six months. However, the process could take longer if any application details or documents are missing or there are scheduling issues with a skill evaluation (if applicable). What supporting documents are required with the application? The documents needed vary with each disabling condition. If you are not physically qualified because of two or more of these disabling physical conditions, then submit the required documentation relating to each of those conditions. Most forms are available for download at Exceptions include forms provided by other agencies, such as a motor vehicle driving record or a federal SPE certificate. NOTE: MoDOT is neither responsible for selecting the medical specialist(s) needed to complete the application, providing the vehicle for a skill evaluation, nor for any expenses incurred. These are the applicant s responsibility. (See the next p for a list of supporting documents)

2 Motor Carrier Services 1320 Creek Trail Drive P.O. Box 270 Jefferson City, MO Toll Free: Fax: ADDITIONAL INSTRUCTIONS FOR APPLICANTS WITH INSULIN-TREATED DIABETES MELLITUS (ITDM) 1 Overview. MoDOT s Director of Motor Carrier Services may grant an exemption from the physical qualification for drivers of commercial motor vehicles (CMVs) required by 49 CFR (b)(3), which requires that a driver has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control. The Director may grant an exemption by issuing a Skill Performance Evaluation (SPE) Certificate for a period up to two years, if MoDOT finds that: such exemption would likely achieve a level of safety that is equivalent to, or greater than, the level that would be achieved absent such exemption.'' 2 Publication of Notice of Application. MoDOT Motor Carrier Services Division must publish a notice of each completed application received, in the Missouri Register, explaining that the application has been filed, and inviting the public to inspect the safety analysis and any other relevant information known to MoDOT Motor Carrier Services Division, and to comment on the application. Prior to granting an application for an exemption, MoDOT Motor Carrier Services Division must publish a second notice in the Missouri Register, identifying the person or class of persons who will receive the exemption, the provisions from which the person will be exempt, the effective period, and all terms and conditions of the exemption. The terms and conditions established by MoDOT Motor Carrier Services Division must ensure that the exemption will likely achieve a level of safety that is equivalent to, or greater than, the level that would be achieved by complying with the regulation. In addition, MoDOT is required to monitor the implementation of each exemption to ensure compliance with its terms and conditions. If the Director denies an application for an exemption, MoDOT Motor Carrier Services Division must publish a notice in the Missouri Register identifying the person whose application is denied, and the reasons for the denial. Renewal and Revocation of Exemption. Generally, the duration of an exemption is limited to not more than two years from the date of approval, but may be renewable upon application to the Director. MoDOT Motor Carrier Services Division is required immediately to revoke an exemption if: (1) The person fails to comply with the terms and conditions of the exemption; (2) The exemption has resulted in a lower level of safety than was maintained before the exemption was granted; or (3) Continuation of the exemption would not be consistent with the goals and objectives of the exemption regulations. Obtaining an Application Packet. Persons who desire to apply for an exemption may mail requests for an application packet to: MoDOT Motor Carrier Services Division, Medical Exemption Program, P.O. Box 270, Jefferson City, MO , or may telephone Kathy J. Hatfield, Motor Carrier Investigations Specialist, at , or (toll free) ext. #6. MoDOT will mail the required forms and instructions. Procedures for Applying for an Exemption. Procedures for the review of exemption applications require MoDOT Motor Carrier Services Division to review a completed application for an exemption, and to prepare, for the Director s signature, a Missouri Register notice requesting public comment. After a review of the comments received, MoDOT Motor Carrier Services Division will make a recommendation to the Director. MoDOT will publish a notice of the Director's final decision in the Missouri Register. The Director will issue a final decision within 180 days of the date MoDOT Motor Carrier Services Division receives an individual's completed application packet. However, if the applicant should omit important details or other information necessary for MoDOT Motor Carrier Services Division to conduct a comprehensive evaluation, the Director will issue a final decision within 180 days of the date that it receives sufficient information. MoDOT recognizes that this potential six-month waiting period may seem burdensome. However, MoDOT must carefully evaluate each and every application for regulatory relief from the diabetes standard, to assess the potential safety performance of each applicant. In addition, MoDOT must prepare and publish notice of each application in the Missouri Register, and then must evaluate comments received before the Director makes a final decision. MoDOT's overriding concern is to ensure the safety of intrastate CMV operations. MoDOT will notify all applicants in writing once the Director makes a final decision. Application Requirements. Every applicant for an exemption must submit an application using MoDOT s completed SPEC-3 FORM, and must include all supporting documentation. In considering exemptions by 1 Adapted from: Authority--Insulin-Treated Diabetes Exemptions Under 49 U.S.C and 31136(e), Federal Register, September 3, 2003 (Volume 68, Number 170) (Notice of Final Disposition); see also Section , Missouri Revised Statutes (RSMo) Supp. 2002; MoDOT Administrative Rule 7 CSR Fed. Reg Page 1 of 4

3 applicants with ITDM, MoDOT Motor Carrier Services Division must ensure that the issuance of a diabetes exemption will not be contrary to the public interest, and that the exemption achieves an acceptable level of safety. MoDOT Motor Carrier Services Division will only grant exemptions; therefore, to ITDM applicants who meet the following requirements: (1) Valid CDL or Drivers License. Possesses a valid intrastate CDL or a license (non-cdl) to operate a CMV; (2) Minimum Period of Insulin Use. Has demonstrated stable control of his/her diabetes through a minimum period of insulin use. The minimum period for Type 1 diabetics is 2 months and for Type 2 diabetics is 1 month; however, a longer period may be required if directed by the treating physician; (3) Safe Driving Record. Has a driving record for the preceding three-year period that: Contains no suspensions or revocations of the applicant's driver's license for the operation of any motor vehicle (including their personal vehicle), Contains no involvement in an accident for which the applicant received a citation for a moving traffic violation while operating a CMV, Contains no involvement in an accident for which the applicant contributed to the cause of the accident, and Contains no convictions for a disqualifying offense or more than one serious traffic violation, as defined in 49 CFR 383.5, while operating a CMV; (4) No Other Disqualifying Conditions. Has no other disqualifying physical conditions, including diabetesrelated complications, which would make the applicant unable to safely operate a CMV; (5) No Recurrent Hypoglycemic Loss of Consciousness or Seizures. Has had no recurrent (two or more) hypoglycemic reactions resulting in a loss of consciousness or seizure within the past five years. A period of one year of demonstrated stability is required following the first episode of hypoglycemia; (6) No Recurrent Hypoglycemic Reactions Requiring Assistance. Has had no recurrent hypoglycemic reactions requiring the assistance of another person within the past five years. A period of one year of demonstrated stability is required following the first episode of hypoglycemia; (7) No Recurrent Hypoglycemic Impairment of Cognitive Function. Has had no recurrent hypoglycemic reactions resulting in impaired cognitive function that occurred without warning symptoms within the past five years. A period of one year of demonstrated stability is required following the first episode of hypoglycemia, (8) Endocrinologist Examination. Has been examined by a board-certified or board-eligible endocrinologist (who is knowledgeable about diabetes) who has conducted a complete medical examination. The complete medical examination must consist of a comprehensive evaluation of the applicant's medical history and current status with a report including the following information: (A) The date insulin use began, (B) Diabetes diagnosis and disease history, (C) Hospitalization records, (D) Consultation notes for diagnostic examinations, (E) Special studies pertaining to the diabetes, (F) Follow-up reports, (G) Reports of any hypoglycemic insulin reactions within the last five years, (H) A current measure of glycosylated hemoglobin (HgA1C), taken during the 30 days immediately before filing the application, (I) Insulin dosages and types, diet utilized for control and any significant factors such as smoking, alcohol use, and other medications or drugs taken, and (J) Examinations to detect any peripheral neuropathy or circulatory insufficiency of the extremities; (9) Endocrinologist Certification. Submits a signed statement from an examining endocrinologist (which must be submitted using MoDOT s completed SPEC-F Form) indicating the following medical determinations: The endocrinologist is familiar with the applicant's medical history for the past five years, either through actual treatment over that time or through consultation with a physician who has treated the applicant during that time; the applicant has been using insulin to control his/her diabetes before the date of the application for the minimum period of insulin use described above; the applicant has been educated in diabetes and its management, thoroughly informed of and understands the procedures which must be followed to monitor and manage his/her diabetes and what procedures should be followed if complications arise; and the applicant has the ability and has demonstrated willingness to properly monitor and manage his/her diabetes; and Page 2 of 4

4 (10) Ophthalmologist or Optometrist Examination and Certification. Submits a separate signed statement from an ophthalmologist or optometrist (which must be submitted using MoDOT s completed SPEC-D Form) that the applicant has been examined and that the applicant does not have diabetic retinopathy and meets the vision standard at 49 CFR (b)(10), or has been issued a valid medical exemption. If the applicant has any evidence of diabetic retinopathy, he or she must be examined by an ophthalmologist and submit a separate signed statement from the ophthalmologist that he or she does not have unstable proliferative diabetic retinopathy (i.e., unstable advancing disease of blood vessels in the retina). Special Driving Conditions Required After Issuance of an Exemption to ITDM Individuals. There are special conditions attached to the issuance of any exemption for ITDM. The Director will impose the following requirements: (1) Medical Supplies for Glucose Management. Individuals with ITDM shall maintain appropriate medical supplies for glucose management while preparing for the operation of a CMV and during its operation. The supplies shall include the following: (A) An acceptable glucose monitor with memory, (B) Supplies needed to obtain adequate blood samples and to measure blood glucose, (C) Insulin to be used as necessary, and (D) An amount of rapidly absorbable glucose to be used as necessary; (2) Driver s Daily Record. Individuals with ITDM shall maintain a daily record of actual driving time which must show the times when the driver performs the daily glucose measurements described in the next paragraph; and (3) Monitoring and Maintaining Blood Glucose Levels. Individuals with ITDM shall self-monitor their blood glucose levels prior to driving, and every two to four hours while driving, using a portable glucose monitoring device equipped with a computerized memory. Prior to and while driving, individuals shall adhere to the following protocol for monitoring and maintaining appropriate blood glucose levels: (1) Check glucose before starting to drive and take corrective action if necessary. If glucose is less than 100 milligrams per deciliter (mg/dl), take glucose or food and recheck in 30 minutes. Do not drive if glucose is less than 100 mg/dl. Repeat the process until glucose is greater than 100 mg/dl; (2) While driving check glucose every two to four hours and take appropriate action to maintain it in the range of 100 to 400 mg/dl; (3) Carry a source of rapidly absorbable glucose, and have food available, at all times when driving. If glucose is less than 100 mg/dl, stop driving and eat. Recheck in 30 minutes and repeat procedure until glucose is greater than 100 mg/dl; and (4) If glucose is greater than 400 mg/dl, stop driving until glucose returns to the 100 to 400 mg/dl range. If more than two hours after last insulin injection and eating, take additional insulin. Recheck blood glucose in 30 minutes. Do not resume driving until glucose is less than 400 mg/dl. Follow-up Documentation to Be Provided to MoDOT. In addition to the requirements for controlling ITDM, MoDOT Motor Carrier Services Division will monitor exemption recipients during the period that the exemption is valid. MoDOT Motor Carrier Services Division will conduct monitoring by requiring the exemption recipients to submit the following information to the Medical Exemption Program, MoDOT Motor Carrier Services Division, P.O. Box 270, Jefferson City, MO (1) Quarterly - Written Confirmation from Endocrinologist. Provide written confirmation from the endocrinologist on a quarterly basis: (A) The make and model of the glucose monitoring device with memory; (B) The individual's blood glucose measurements and glycosylated hemoglobin are generally in an adequate range based on: a. All daily glucose measurements taken with the glucose monitoring device and correlated with the daily records of driving time; and b. A current measurement of glycosylated hemoglobin. (2) Annually - Comprehensive Medical Evaluation by Endocrinologist. Submit on an annual basis, a comprehensive medical evaluation by an endocrinologist. The evaluation will include a general physical examination and a report of glycosylated hemoglobin concentration. The evaluation will also involve an assessment of the individual's willingness and ability to monitor and manage the diabetic condition; (3) Annually - Confirmation of No Diabetic Retinopathy. Provide on an annual basis confirmation by an ophthalmologist or optometrist that there is no diabetic retinopathy and the individual meets the current vision standards at 49 CFR (b)(10). If there is any evidence of diabetic retinopathy, provide annual Page 3 of 4

5 documentation by an ophthalmologist that the individual does not have unstable proliferative diabetic retinopathy; (4) Annually - Documentation of Ongoing Education. Submit annual documentation by an endocrinologist of ongoing education in management of diabetes and hypoglycemia awareness; (5) Report All Episodes Relating to Diabetes. Report all episodes of severe hypoglycemia, significant complications, or inability to manage diabetes; and (6) Report Any Accident Involvement. Report any involvement in an accident or any other adverse event whether or not they are related to an episode of hypoglycemia. Medical Examination-Certificate of Physical Examination. Because diabetes is a chronic disease requiring constant control and monitoring, MoDOT Motor Carrier Services Division will impose conditions on ITDM individuals who have been issued an exemption. The required conditions include the following: (1) Yearly Physical Examination. Each individual must have a physical examination every year: (a) The physical examination must first be conducted by an endocrinologist indicating the driver is: 1. Free of insulin reactions. ``Free of insulin reactions'' in this context means that the individual has had: (A) No recurrent (two or more) hypoglycemic reactions resulting in a loss of consciousness or seizure within the past five years. A period of one year of demonstrated stability is required following the first episode of hypoglycemia, (B) No recurrent hypoglycemic reactions requiring the assistance of another person within the past five years. A period of one year of demonstrated stability is required following the first episode of hypoglycemia, and (C) No recurrent hypoglycemic reactions resulting in impaired cognitive function that occurred without warning symptoms within the past five years. A period of one year of demonstrated stability is required following the first episode of hypoglycemia, 2. Able to and has demonstrated willingness to properly monitor and manage his/her diabetes, and 3. Will not likely suffer any diminution in driving ability due to his/her diabetic condition; and (b) Secondly, the physical examination must be conducted by a medical examiner who attests that the individual is physically qualified under 49 CFR , or holds a valid exemption or SPE Certificate. (2) Compliance Conditions. Each individual must agree to and must comply with the following conditions: (a) Submit blood glucose records to both the endocrinologist and medical examiner at the annual examinations or when otherwise directed by an authorized agent of MoDOT Motor Carrier Services Division; and (b) Provide a copy of the endocrinologist's report to the medical examiner at the time of the annual medical examination; and (3) Provide Report Indicating No Diabetic Retinopathy. Each individual must provide a copy of the optometrist's or ophthalmologist's report indicating that there is no diabetic retinopathy and the individual meets the current vision standards at 49 CFR (b)(10). If there is any evidence of diabetic retinopathy, the individual must provide to the medical examiner at the time of the annual medical examination a copy of the ophthalmologist's report indicating that the individual does not have unstable proliferative diabetic retinopathy; and (4) Provide Annual Medical Certification To Employer. Each individual must provide a copy of the annual medical certification to the employer for retention in the driver's qualification file, or must keep a copy in his/her driver's qualification file if he/she is self-employed. The driver must also have a copy of the certification when driving for presentation to a duly authorized Federal, State, or local enforcement official. Page 4 of 4

6 ALL APPLICATIONS The following documents must be completed and submitted with every application for a SPE Certificate: Statement of Treating Physician (SPEC B FORM) Waiver or Privacy Regarding Personal Health Information (SPEC C FORM) HIPAA Compliant Authorization for Release of Information Physical Examination Form and Medical Examiner's Certificate Form Road Test and Road Test Certification Form. A motor carrier or a person who is competent to administer the test and evaluate its results must administer the road test. Driver Employment Application Form. This form is provided for your use if you do not have a copy of the last one you completed for your last employer. Copy of State motor vehicle driving record (MVR) for the past 3 years from each State in which you held a driver's license or permit. * Available through the Missouri Department of Revenue Copy of your interstate SPE certificate, exemption or waiver of certain physical defects issued by FMCSA or the individual State(s), if applicable. *Available from the FMCSA and/or other states LIMB IMPAIRMENT OR AMPUTATION FORMS A board certified or board eligible orthopedic surgeon, doctor of physical medicine or physiatrist must complete the Medical Evaluation Summary. Although you may choose any qualified medical specialist, we recommend that you go to a physical rehabilitation facility for this examination. These facilities and their personnel generally have more experience in evaluating the amputee or a limb impaired individual. Application for Skill Performance Evaluation Certificate to Operate Intrastate Commercial Motor Vehicles (Applicant with Limb Impairment or Amputation) (SPEC 1 FORM) Medical Evaluation Summary (SPEC A FORM) (Limb Impairment or Amputation Only) VISION IMPAIRMENT Application for Skill Performance Evaluation (SPE) Certificate to Operate Intrastate Commercial Motor Vehicles (Applicant with Impaired Vision) (SPEC 2 FORM) Optometrist/Ophthalmologist Certification (SPEC D FORM) Affidavit of Driving Experience (SPEC E FORM) INSULIN TREATED DIABETES MELLITUS. Application for Skill Performance Evaluation (SPE) Certificate to Operate Intrastate Commercial Motor Vehicles (Applicant with Insulin Treated Diabetes Mellitus (ITDM)) (SPEC 3 FORM) Optometrist/Ophthalmologist Certification (SPEC D FORM) Affidavit of Driving Experience (SPEC E FORM) Endocrinologist Certification (SPEC F FORM) Questions? Contact the MoDOT Motor Carrier Services Safety and Compliance team. Call toll-free, Return completed application and supporting documents to: ATTN: MEDICAL EXEMPTION PROGRAM MoDOT Motor Carrier Services P.O. Box 270 Jefferson City, MO

7 DRIVER'S ROAD TEST EXAMINATION Driver's Name: Address: City: State: Zip: Phone: Cell: The motor carrier shall give the road test or a person designated by it. However, another person must give a driver who is a motor carrier the test. A person who is competent to evaluate and determine whether the person who takes the test has demonstrated that he or she is capable of operating the vehicle and associated equipment that the motor carrier intends to assign shall give the test. Rating of Performance The pre trip inspection (As required by Sec ) Coupling and uncoupling of combination units, if the equipment he or she may drive includes combination units. Placing the equipment in operation. Use of vehicle's controls and emergency equipment. Operating the vehicle in traffic and while passing other vehicles. Turning the vehicle. Braking, and slowing the vehicle by means other than braking. Backing and parking the vehicle. Other, Explain: Type of equipment used in giving test: Examiner's Signature: Date: Page 1 of 4 (version )

8 RECORD OF ROAD TEST Instructions to Evaluator: Check ( ) items which the driver performs satisfactorily, use "X" where performance is unsatisfactory. Any item not evaluated, leave blank. Driver's Name _ Home Address Social Security No. License No. State Class _ Equipment Driven: Truck Tractor Trailer(s) (Make & Model) (Body Type & Length of Each) Length of Test Mi. From/In To Start Time _ Finish Time Weather Conditions PART 1 PRE TRIP INSPECTION AND EMERGENCY EQUIPMENT PART 3 PLACING VEHICLE IN MOTION AND USE OF CONTROLS Checks general condition approaching unit Checks fuel, oil. Water and for excessive oil on engine Checks around unit - Tires, lights, trailer hook-up, brake and light line, doors and inspects for body damage Tests steering, brake action, tractor protection valve, and parking brake Checks horn, windshield wipers, mirrors, emergency equipment; reflectors, flares, fuses, tire chains (if necessary), fire equipment Checks instruments for normal readings Checks dashboard warning lights for proper functioning Cleans windshield, windows, mirrors, lights and reflectors Reviews and signs previous report PART 2 COUPLING AND UNCOUPLING Connects glad hands to trailer to apply trailer brakes before coupling Connects glad hands and light line properly Couples without difficulty Raises landing gear fully after coupling Visually checks king pin assembly to be certain of proper coupling Checks coupling by applying hand valve or tractor-pro tection valve (trailer air supply valve) and gently applying pressure by trying to pull away from trailer Assures himself that surface will support trailer before uncoupling A. MOTOR Places transmission in neutral before starting engine Starts engine without difficulty Checks instruments at regular intervals Maintains proper engine rpm while driving B. BRAKES Knows proper use of and checks tractor-protection valve (trailer air supply valve) Tests service brakes Builds full air pressure before moving C. CLUTCH AND TRANSMISSION Starts unit moving smoothly Uses clutch properly D. LIGHTS (if tested at night) Adjusts speed for range of headlights Dims lights when approaching another vehicle or following other traffic PART 4 BACKING AND PARKING A. BACKING Gets out and checks area before backing Understands and utilizes mirrors properly Signals when backing (if appropriate) Avoids backing from blind side B. PARKING (CITY) Parks without hitting any other vehicles or stationary objects Parks correct distance from curb Secures unit properly - sets parking brake, trans mission in correct gear, shuts off engine, blocks wheels (when necessary) Carefully enters traffic from parked position C. PARKING (ROAD) Parks off pavement Secures unit properly Uses emergency warning signal or devices when necessary Page 2 of 4 (version )

9 PART 5 SLOWING AND STOPPING Uses clutch and gears properly Gears down properly before descending hills Starts without rolling back Tests brakes before descending grades Uses brakes properly on grades Makes proper use of mirrors Plans stop far enough in advance to avoid hard braking Stops clear of cf crosswalks PART 6 OPERATING IN TRAFFIC, PASSING AND TURNING A. TURNING Signals intention to turn well in advance Gets into proper lane well in advance of turn Checks traffic conditions and turns only when intersction is clear Restricts traffic from passing on right when perparing to complete right hand turn Completes turn promptly and safely and does not impede other traffic B. TRAFFIC SIGNS AND SIGNALS Plans stop in advance and adjusts speed correctly Obeys all traffic signals Comes to a complete stop at all stop signs C. INTERSECTIONS Yields right of way Checks for cross traffic regardless of traffic controls Enters all intersections prepared to stop if necessary D. GRADE CROSSINGS Stops at a minimum 15 feet but not more than 50 feet before crossing if stop is necessary Selects proper gear and does not shift gears while crossing Knows and understands Federal and State rules governing grade crossings E. PASSING Allows sufficient space ahead for passing Passes only in safe locations Signals changing lanes before and after passing Warns driver ahead of his intention to pass Passes with sufficient speed differential to minimize obstructing traffic Returns to right lane promptly but only when safe to do so F. SPEED Observes speed limits Drives at speed consistent with ability Adjusts speed properly to road, weather and traffic conditions Slows down in advance of curves, danger zones and intersections Maintains constant speed where possible G. COURTESY AND SAFETY Yields right of way Consistently strives to drive in safe manner Allows faster traffic to pass Uses horn only when necessary PART 7 MISCELLANEOUS A. GENERAL DRIVING ABILITY AND HABITS Consistently alert and attentive Consistently is aware of changing traffic conditions anticipates problems Performs routine functions without taking eyes from road Checks instruments regularly while driving Personal appearance is professional Remains calm under pressure B. USE OF SPECIAL EQUIPMENT (SPECIFY) REMARKS: GENERAL PERFORMANCE: Satisfactory Needs Training Explain: QUALIFIED FOR: Straight Truck Tractor Semitrailer Twin Trailers Other Combination Special Equipment (SPECIFY) Date SIGNATURE OF EXAMINER Page 3 of 4 (version )

10 CERTIFICATION OF ROAD TEST Driver's Name (Social Security Number) (Operators or Chauffeurs License Number) (State) Type of Power Unit Type of Trailer(s) If passenger carrier, type of bus This is to certify that the above named driver was given a road test under my supervision on, 20 consisting of approximately miles of driving. It is my considered opinion that this driver possesses sufficient driving skill to operate safely the type of commercial motor vehicle listed above. (Signature of Examiner) _ (Title) (Organization and Address of Examiner) Page 4 of 4 (version )

11 APPLICATION FOR EMPLOYMENT COMPANY STREET ADDRESS CITY, STATE AND ZIP CODE NAME (FIRST) (MIDDLE) (Maiden Name, if any) (LAST) ADDRESS (STREET) (CITY) (STATE & ZIP CODE) HOW LONG? DATE OF BIRTH SOCIAL SECURITY NO. _ TELEPHONE NUMBER _ E MAIL ADDRESS ADDRESS FOR PAST THREE YEARS (STREET) (CITY) (STATE & ZIP CODE) (STREET) (CITY) (STATE & ZIP CODE) (ATTACH SHEET IF MORE SPACE IS NEEDED) EXPERIENCE AND QUALIFICATIONS DRIVER HOW LONG? HOW LONG? DRIVER STATE LICENSE NO. TYPE EXPIRATION DATE LICENSES DRIVING EXPERIENCE CLASS OF EQUIPMENT TYPE OF EQUIPMENT (VAN, TANK, FLAT, ETC.) DATES FROM TO APPROX. NO. OF MILES (TOTAL) STRAIGHT TRUCK TRACTOR AND SEMI TRAILER TRACTOR TWO TRAILERS OTHER ACCIDENT RECORD FOR PAST 3 YEARS OR MORE (ATTACH SHEET IF MOR SPACE IS NEEDED) DATES NATURE OF ACCIDENT (HEAD ON, REAR END, UPSET, ETC.) FATALITIES INJURIES LAST ACCIDENT NEXT PREVIOUS NEXT PREVIOUS (version ) Page 1 of 2

12 TRAFFIC CONVICTIONS AND FORFEITURES FOR THE PAST 3 YEARS (OTHER THAN PARKING VIOLATIONS) LOCATION DATE CHARGE PENALTY (ATTACH SHEET IF MORE SPACE IS NEEDED) A. Have you ever been denied a license, permit or privilege to operate a motor vehicle? YES NO B. Has any license, permit or privilege ever been suspended or revoked? YES NO (IF THE ANSWER TO EITHER A OR B IS YES, ATTACH STATEMENT GIVING DETAILS) EMPLOYMENT RECORD (Attach Sheet If More Space Is Needed) NOTE: DOT requires that employment for at least 3 years and/or commercial driving experience for the past 10 years be shown. LAST EMPLOYER: NAME ADDRESS POSITION HELD FROM TO SALARY REASONS FOR LEAVING SECOND LAST EMPLOYER: NAME _ ADDRESS POSITION HELD FROM TO SALARY REASONS FOR LEAVING THIRD LAST EMPLOYER: NAME ADDRESS POSITION HELD FROM TO SALARY REASONS FOR LEAVING TO BE READ AND SIGNED BY APPLICANT This certifies that I completed this application, and that all entries on it and information in it are true and complete to the best of my knowledge. DATE APPLICANT'S SIGNATURE Note: A motor carrier may require an applicant to provide information in addition to the information required by the Federal Motor Carrier Safety Regulations. Page 2 of 2 (version )

13 HIPAA-COMPLIANT AUTHORIZATION FOR RELEASE OF INFORMATION PURSUANT TO 45 C.F.R Patient Name: Date of Birth: Provider/Covered Entity: (Organizations, individuals, or classes of persons requested to disclose patient information) Name: Address: (To be completed by Motor Carrier Services:) Requestors: (To whom the provider/covered entity is requested to disclose patient information): Missouri Highways and Transportation Commission, and/or Missouri Department of Transportation, Motor Carrier Services Division. ATTN: Medical Exemption Program Motor Carrier Services P.O. Box Jefferson City, MO TEL: (573) ; FAX: (573) Information Requested: The Patient identified above authorizes the disclosure of all protected medical information in any form (including oral, written and electronic) to the Requestors listed above, and Requestors re-disclosure of the data and information to its agents, consultants, counsel, and whomever Requestors deems reasonable and necessary to further the administration of the Skill Performance Evaluation Certification program. Patient expressly requests that all covered entities under HIPAA identified above shall disclose full and complete protected health information concerning the Patient, relating to the time period beginning on and ending on, inclusive. This includes, but is not limited to, the following: All medical records, including, but not limited to: inpatient & emergency room treatment; all clinical charts, reports, documents, correspondence, test results, statements, questionnaires/histories, examination reports, office and doctor s handwritten notes, and records received from other physicians or health care providers; All laboratory, histology, cystology, pathology, radiology, CT scan, MRI, echocardiogram reports; All radiology films; All pharmacy prescription records. Purposes of Release: Release of this information is requested for the purposes of evaluating, reviewing, and monitoring the patient s qualifications to operate commercial motor vehicles safely, in connection with the patient s application for issuance of a Skill Performance Evaluation Certificate by the Missouri Department of Transportation, Motor Carrier Services Division. This authorization is effective until the later of, or the date when my application for issuance of a Skill Performance Evaluation Certificate is finally determined, or (if the application is granted) the date when my SPE Certificate expires. I understand that I may revoke this authorization at any time, by giving written notice to the Missouri Department of Transportation, Motor Carrier Services Division, at the address mentioned above. I understand that revocation is only effective after the written notice is received by MoDOT Motor Carrier Services Division, and that any use or disclosure of the information under this authorization, made before the revocation is effective, will not be affected by the revocation. I understand that I am entitled to receive a copy of this authorization. I understand that, after information is released under this authorization, it may be re-disclosed by the recipient, and if redisclosed, the information will no longer be protected by federal or state privacy rules. I understand that the covered entity to which this authorization is directed may not condition treatment, payment, enrollment, or eligibility benefits on whether or not I sign this authorization. Any facsimile, copy or photocopy of the authorization authorizes the release of all records requested herein. Signature of Patient: Date: In addition to the authorization and other provisions contained above, hereby incorporated by reference, I authorize the release of mental health records (includes psychological testing) to Requestors and re-disclosure of the data and information to their agents, counsel or whomever Requestors deems reasonable and necessary to further the administration of my Skill Performance Evaluation Certificate application. This includes any and all data, notes, records, reports and information protected by state and federal law. Signature of Patient: Date: X:\wallat\Posted on Web\Medical Forms\HIPAAcompliantReleaseForm.doc

14 Medical Examination Report FOR COMMERCIAL DRIVER FITNESS DETERMINATION 649-F (6045) 1. DRIVER'S INFORMATION Driver completes this section Driver's Name (Last, First, Middle) Social Security No. Birthdate Age Sex New Certification M Recertification M / D / Y F Follow-up Date of Exam Address City, State, Zip Code Work Tel: ( ) Driver License No. License Class State of Issue A C Home Tel: ( ) B D Other 2. Yes No HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver. Yes No Lung disease, emphysema, asthma, chronic bronchitis Fainting, dizziness Any illness or injury in the last 5 years? Kidney disease, dialysis Sleep disorders, pauses in breathing Head/Brain injuries, disorders or illnesses Liver disease while asleep, daytime sleepiness, loud Seizures, epilepsy Digestive problems snoring medication_ Diabetes or elevated blood sugar controlled by: Stroke or paralysis Eye disorders or impaired vision (except corrective lenses) diet Missing or impaired hand, arm, foot, leg, Ear disorders, loss of hearing or balance pills finger, toe Heart disease or heart attack; other cardiovascular condition insulin Spinal injury or disease medication_ Nervous or psychiatric disorders, e.g., severe depression medication Chronic low back pain Heart surgery (valve replacement/bypass, angioplasty, pacemaker) Regular, frequent alcohol use Loss of, or altered consciousness High blood pressure medication_ Narcotic or habit forming drug use Muscular disease Shortness of breath For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including over-the-counter medications) used regularly or recently. Yes No I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate. Driver's Signature Date Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of medications, including over-the-counter medications, while driving. This discussion must be documented below. )

15 TESTING (Medical Examiner completes Section 3 through 7) Name: Last, First, Middle, 3. VISION Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate. INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified. Numerical readings must be provided. Applicant can recognize and distinguish among traffic control Yes signals and devices showing standard red, green, and amber colors? ACUITY UNCORRECTED CORRECTED HORIZONTAL FIELD OF VISION No Right Eye 20/ 20/ Right Eye Left Eye 20/ 20/ Left Eye Both Eyes 20/ 20/ Complete next line only if vision testing is done by an opthalmologist or optometrist Applicant meets visual acuity requirement only when wearing: Corrective Lenses Monocular Vision: Yes No Date of Examination Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature 4. HEARING Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 db Check if hearing aid used for tests. Check if hearing aid required to meet standard. INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 db from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 db for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3. Numerical readings must be recorded. Right Ear Left Ear a) Record distance from individual at which Right ear Left Ear b) If audiometer is used, record hearing loss in 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz forced whispered voice can first be heard. \ Feet \ Feet decibels. (acc. to ANSI Z ) Average: Average: 5. BLOOD PRESSURE/ PULSE RATE Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP. Blood Systolic Diastolic Pressure Driver qualified if <140/90. Pulse Rate: Regular Irregular Reading Category Expiration Date Recertification /90-99 Stage 1 1 year 1 year if <140/90. One-time certificate for 3 months if / / Stage 2 One-time certificate for 3 months. 1 year from date of exam if <140/90 >180/110 Stage 3 6 months from date of exam if <140/90 6 months if < 140/90 6. LABORATORY AND OTHER TEST FINDINGS Numerical readings must be recorded. SP. GR. PROTEIN BLOOD SUGAR URINE SPECIMEN Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem. Other Testing (Describe and record)

16 7. 7 PHYSICAL EXAMINATION Height: (in.) Weight: (lbs.) Name: Last, First, Middle, The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving. Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. See Instructions to the Medical Examiner for guidance. BODY SYSTEM 1. General Appearance 2. Eyes CHECK FOR: Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse. Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement, nystagmus, exophthalmos. Ask about retinopathy, cataracts, aphakia, glaucoma, macular degeneration and refer to a specialist if appropriate. YES* NO BODY SYSTEM 7. Abdomen and Viscera 8. Vascular System 9. Genito-urinary System CHECK FOR: Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal wall muscle weakness. Abnormal pulse and amplitude, cartoid or arterial bruits, varicose veins. Hernias. YES* NO 3. Ears 4. Mouth and Throat 5. Heart 6. Lungs and chest, not including breast examination Scarring of tympanic membrane, occlusion of external canal, perforated eardrums. Irremediable deformities likely to interfere with breathing or swallowing. Murmurs, extra sounds, enlarged heart, pacemaker, implantable defibrillator. Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales, impaired respiratory function, cyanosis. Abnormal findings on physical exam may require further testing such as pulmonary tests and/ or xray of chest. 10. Extremities- Limb impaired. Driver may be subject to SPE certificate if otherwise qualified. 11. Spine, other musculoskeletal 12. Neurological Loss or impairment of leg, foot, toe, arm, hand, finger, Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia. Insufficicent grasp and prehension in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly. Previous surgery, deformities, limitation of motion, tenderness. Impaired equilibrium, coordination or speech pattern; asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinki's reflexes, ataxia. *COMMENTS: Note certification status here. See Instructions to the Medical Examiner for guidance. Wearing corrective lense Wearing hearing aid Meets standards in 49 CFR ; qualifies for 2 year certificate Accompanied by a waiver/ exemption. Driver must present Does not meet standards exemption at time of certification. Meets standards, but periodic monitoring required due to. Skill Performanc e Evaluation (SPE) Certificate Driver qualified only for: 3 months 6 months 1 year Other Driving within an exempt intracity zone (See 49 CFR ) Qualified by operation of 49 CFR Medical Examiner's signature Temporarily disqualified due to (condition or medication): Medical Examiner's name Address Return to medical examiner's office for follow up on Telephone Number If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR (h). (Driver must carry certificate when operating a commercial vehicle.)

17 49 CFR Physical Qualifications for Drivers THE DRIVER'S ROLE Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main types of drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off-duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.) The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight pickup and delivery schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature. Transporting passengers or hazardous materials may add to the demands on the commercial driver. There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long period of time without any stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and, lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s). In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary, and the manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas PHYSICAL QUALIFICATIONS FOR DRIVERS (a) A person shall not drive a commercial motor vehicle unless he is physically qualified to do so and, except as provided in , has on his person the original, or a photographic copy, of a medical examiner's certificate that he is physically qualified to drive a commercial motor vehicle. (b) A person is physically qualified to drive a motor vehicle if that person: (1) Has no loss of a foot, a leg, a hand, or an arm, or has been granted a Skill Performance Evaluation (SPE) Certificate (formerly Limb Waiver Program) pursuant to (2) Has no impairment of: (i) A hand or finger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or has been granted a SPE Certificate pursuant to (3) Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control; (4) Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis, or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse, or congestive cardiac failure. (5) Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with his ability to control and drive a commercial motor vehicle safely. (6) Has no current clinical diagnosis of high blood pressure likely to interfere with his ability to operate a commercial motor vehicle safely. (7) Has no established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular, or vascular disease which interferes with his ability to control and operate a commercial motor vehicle safely. (8) Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a commercial motor vehicle; (9) Has no mental, nervous, organic, or functional disease or psychiatric disorder likely to interfere with his ability to drive a commercial motor vehicle safely; (10) Has distant visual acuity of at least 20/40 (Snellen) in each eye without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green and amber; (11) First perceives a forced whispered voice in the better ear not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or without a hearing device when the audiometric device is calibrated to the American National Standard (formerly ASA Standard) Z ; (12) (i) Does not use a controlled substance identified in 21 CFR Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. (ii) Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who: (A) Is familiar with the driver's medical history and assigned duties; and (B) Has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle; and (13) Has no current clinical diagnosis of alcoholism.

18 INSTRUCTIONS TO THE MEDICAL EXAMINER General Information The purpose of this examination is to determine a driver's physical qualification to operate a commercial motor vehicle (CMV) in interstate commerce according to the requirements in 49 CFR Therefore, the medical examiner must be knowledgeable of these requirements and guidelines developed by the FMCSA to assist the medical examiner in making the qualification determination. The medical examiner should be familiar with the driver's responsibilities and work environment and is referred to the section on the form, The Driver's Role. In addition to reviewing the Health History section with the driver and conducting the physical examination, the medical examiner should discuss common prescriptions and over-the-counter medications relative to the side effects and hazards of these medications while driving. Educate the driver to read warning labels on all medications. History of certain conditions may be cause for rejection, particularly if required by regulation, or may indicate the need for additional laboratory tests or more stringent examination perhaps by a medical specialist. These decisions are usually made by the medical examiner in light of the driver's job responsibilities, work schedule and potential for the conditions to render the driver unsafe. Medical conditions should be recorded even if they are not cause for denial, and they should be discussed with the driver to encourage appropriate remedial care. This advice is especially needed when a condition, if neglected, could develop into a serious illness that could affect driving. If the medical examiner determines that the driver is fit to drive and is also able to perform non-driving responsibilities as may be required, the medical examiner signs the medical certificate which the driver must carry with his/her license. The certificate must be dated. Under current regulations, the certificate is valid for two years, unless the driver has a medical condition that does not prohibit driving but does require more frequent monitoring. In such situations, the medical certificate should be issued for a shorter length of time. The physical examination should be done carefully and at least as complete as is indicated by the attached form. Contact the FMCSA at (202) for further information (a vision exemption, qualifying drivers under 49 CFR , etc.). Interpretation of Medical Standards Since the issuance of the regulations for physical qualifications of commercial drivers, the Federal Motor Carrier Safety Administration (FMCSA) has published recommendations called Advisory Criteria to help medical examiners in determining whether a driver meets the physical qualifications for commercial driving. These recommendations have been condensed to provide information to medical examiners that (1) is directly relevant to the physical examination and (2) is not already included in the medical examination form. The specific regulation is printed in italics and it's reference by section is highlighted. Federal Motor Carrier Safety Regulations -Advisory Criteria- Loss of Limb: (b)(1) A person is physically qualified to drive a commercial motor vehicle if that person: Has no loss of a foot, leg, hand or an arm, or has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section Limb Impairment: (b)(2) A person is physically qualified to drive a commercial motor vehicle if that person: Has no impairment of: (i) A hand or finger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iii) Any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iv) Has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section A person who suffers loss of a foot, leg, hand or arm or whose limb impairment in any way interferes with the safe performance of normal tasks associated with operating a commercial motor vehicle is subject to the Skill Performance Evaluation Certification Program pursuant to section , assuming the person is otherwise qualified. With the advancement of technology, medical aids and equipment modifications have been developed to compensate for certain disabilities. The SPE Certification Program (formerly the Limb Waiver Program) was designed to allow persons with the loss of a foot or limb or with functional impairment to qualify under the Federal Motor Carrier Safety Regulations (FMCSRs) by use of prosthetic devices or equipment modifications which enable them to safely operate a commercial motor vehicle. Since there are no medical aids equivalent to the original body or limb, certain risks are still present, and thus restrictions may be included on individual SPE certificates when a State Director for the FMCSA determines they are necessary to be consistent with safety and public interest. If the driver is found otherwise medically qualified (391.41(b)(3) through (13)), the medical examiner must check on the medical certificate that the driver is qualified only if accompanied by a SPE certificate. The driver and the employing motor carrier are subject to appropriate penalty if the driver operates a motor vehicle in interstate or foreign commerce without a curent SPE certificate for his/her physical disability. Diabetes (b)(3) A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control. Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or disorientation in time and space. Individuals who require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semiconsciousness, diabetic coma or insulin shock). The administration of insulin is, within itself, a complicated process requiring insulin, syringe, needle, alcohol sponge and a sterile technique. Factors related to long-haul commercial motor vehicle operations, such as fatigue, lack of sleep, poor diet, emotional conditions, stress, and concomitant illness, compound the dangers, the FMCSA has consistently held that a diabetic who uses insulin for control does not meet the minimum physical requirements of the FMCSRs. Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualified under the present rule. CMV drivers who do not meet the Federal diabetes standard may call (202) for an application for a diabetes exemption. (See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: Cardiovascular Condition (b)(4) A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse or congestive cardiac failure. The term "has no current clinical diagnosis of" is specifically designed to encompass: "a clinical diagnosis of" (1) a current cardiovascular condition, or (2) a cardiovascular condition which has not fully stabilized regardless of the time limit The term "known to be

19 accompanied by" is designed to include a clinical diagnosis of a cardiovascular disease (1) which is accompanied by symptoms of syncope, dyspnea, collapse or congestive cardiac failure; and/or (2) which is likely to cause syncope, dyspnea, collapse or congestive cardiac failure. It is the intent of the FMCSRs to render unqualified, a driver who has a current cardiovascular disease which is accompanied by and/or likely to cause symptoms of syncope, dyspnea, collapse, or congestive cardiac failure. However, the subjective decision of whether the nature and severity of an individual's condition will likely cause symptoms of cardiovascular insufficiency is on an individual basis and qualification rests with the medical examiner and the motor carrier. In those cases where there is an occurrence of cardiovascular insufficiency (myocardial infarction, thrombosis, etc.), it is suggested before a driver is certified that he or she have a normal resting and stress electrocardiogram (ECG), no residual complications and no physical limitations, and is taking no medication likely to interfere with safe driving. Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus, not unqualifying. Implantable cardioverter defibrillators are disqualifying due to risk of syncope. Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver. The emphasis should be on the underlying medical condition(s) which require treatment and the general health of the driver. The FMCSA should be contacted at (202) for additional recommendations regarding the physical qualification of drivers on coumadin. (See Cardiovasular Advisory Panel Guidelines for the Medical examination of Commercial Motor Vehicle Drivers at: Respiratory Dysfunction (b)(5) A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with ability to control and drive a commercial motor vehicle safely. Since a driver must be alert at all times, any change in his or her mental state is in direct conflict with highway safety. Even the slightest impairment in respiratory function under emergency conditions (when greater oxygen supply is necessary for performance) may be detrimental to safe driving. There are many conditions that interfere with oxygen exchange and may result in incapacitation, including emphysema, chronic asthma, carcinoma, tuberculosis, chronic bronchitis and sleep apnea. If the medical examiner detects a respiratory dysfunction, that in any way is likely to interfere with the driver's ability to safely control and drive a commercial motor vehicle, the driver must be referred to a specialist for further evaluation and therapy. Anticoagulation therapy for deep vein thrombosis and/or pulmonary thromboembolism is not unqualifying once optimum dose is achieved, provided lower extremity venous examinations remain normal and the treating physician gives a favorable recommendation. Hypertension (b)(6) A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of high blood pressure likely to interfere with ability to operate a commercial motor vehicle safely. Hypertension alone is unlikely to cause sudden collapse; however, the likelihood increases when target organ damage, particularly cerebral vascular disease, is present. This regulatory criteria is based on FMCSA's Cardiovascular Advisory Guidelines for the Examination of CMV Drivers, which used the Sixth Report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure (1997). Stage 1 hypertension corresponds to a systolic BP of mmhg and/or a diastolic BP of mmhg. The driver with a BP in this range is at low risk for hypertension-related acute incapacitation and may be medically certified to drive for a one-year period. Certification examinations should be done annually thereafter and should be at or less than 140/90. If less than 160/100, certification may be extended one time for 3 months. A blood pressure of systolic and/or diastolic is considered Stage 2 hypertension, and the driver is not necessarily unqualified during evaluation and institution of treatment. The driver is given a one time certification of three months to reduce his or her blood pressure to less than or equal to 140/90. A blood pressure in this range is an absolute indication for anti-hypertensive drug therapy. Provided treatment is well tolerated and the driver demonstrates a BP value of 140/90 or less, he or she may be certified for one year from date of the initial exam. The driver is certified annually thereafter. A blood pressure at or greater than 180 (systolic) and 110 (diastolic) is considered Stage 3, high risk for an acute BP-related event. The driver may not be qualified, even temporarily, until reduced to 140/90 or less and treatment is well tolerated. The driver may be certified for 6 months and biannually (every 6 months) thereafter if at recheck BP is 140/90 or less. Annual recertification is recommended if the medical examiner does not know the severity of hypertension prior to treatment. An elevated blood pressure finding should be confirmed by at least two subsequent measurements on different days. Treatment includes nonpharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors. Most antihypertensive medications also have side effects, the importance of which must be judged on an individual basis. Individuals must be alerted to the hazards of these medications while driving. Side effects of somnolence or syncope are particulary undesirable in commercial drivers. Secondary hypertension is based on the above stages.

20 Epilepsy (b)(8) A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a motor vehicle. Epilepsy is a chronic functional disease characterized by seizures or episodes that occur without warning, resulting in loss of voluntary control which may lead to loss of consciousness and/or seizures. Therefore, the following drivers cannot be qualified: (1) a driver who has a medical history of epilepsy; (2) a driver who has a current clinical diagnosis of epilepsy; or (3) a driver who is taking antiseizure medication. If an individual has had a sudden episode of a nonepileptic seizure or loss of consciousness of unknown cause which did not require antiseizure medication, the decision as to whether that person's condition will likely cause loss of consciousness or loss of ability to control a motor vehicle is made on an individual basis by the medical examiner in consultation with the treating physician. Before certification is considered, it is suggested that a 6 month waiting period elapse from the time of the episode. Following the waiting period, it is suggested that the individual have a complete neurological examination. If the results of the examination are negative and antiseizure medication is not required, then the driver may be qualified. In those individual cases where a driver has a seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction, high temperature, acute infectious disease, dehydration or acute metabolic disturbance), certification should be deferred until the driver has fully recovered from that condition and has no existing residual complications, and not taking antiseizure medication. Drivers with a history of epilepsy/seizures off antiseizure medication and seizure-free for 10 years may be qualified to drive a CMV in interstate commerce. Interstate drivers with a history of a single unprovoked seizure may be qualified to drive a CMV in interstate commerce if seizure-free and off antiseizure medication for a 5-year period or more. (See Conference on Neurological Disorders and Commercial Drivers at: Mental Disorders (b)(9) A person is physically qualified to drive a commercial motor vehicle if that person: Has no mental, nervous, organic or functional disease or psychiatric disorder likely to interfere with ability to drive a motor vehicle safely. Emotional or adjustment problems contribute directly to an individual's level of memory, reasoning, attention, and judgment. These problems often underlie physical disorders. A variety of functional disorders can cause drowsiness, dizziness, confusion, weakness or paralysis that may lead to incoordination, inattention, loss of functional control and susceptibility to accidents while driving. Physical fatigue, headache, impaired coordination, recurring physical ailments and chronic "nagging" pain may be present to such a degree that certification for commercial driving is inadvisable. Somatic and psychosomatic complaints should be thoroughly examined when determining an individual's overall fitness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualification. Many bus and truck drivers have documented that "nervous trouble" related to neurotic, personality, or emotional or adjustment problems is responsible for a significant fraction of their preventable accidents. The degree to which an individual is able to appreciate, evaluate and adequately respond to environmental strain and emotional stress is critical when assessing an individual's mental alertness and flexibility to cope with the stresses of commercial motor vehicle driving. When examining the driver, it should be kept in mind that individuals who live under chronic emotional upsets may have deeply ingrained maladaptive or erratic behavior patterns. Excessively antagonistic, instinctive, impulsive, openly aggressive, paranoid or severely depressed behavior greatly interfere with the driver's ability to drive safely. Those individuals who are highly susceptible to frequent states of emotional instability (schizophrenia, affective psychoses, paranoia, anxiety or depressive neuroses) may warrant disqualification. Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination. See Psychiatric Conference Report for specific recommendations on the use of medications and potential hazards for driving. (See Conference on Psychiatric Disorders and Commercial Drivers at: Vision (b)(10) A person is physically qualified to drive a commercial motor vehicle if that person: Has distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber. The term "ability to recognize the colors of" is interpreted to mean if a person can recognize and distinguish among traffic control signals and devices showing standard red, green and amber, he or she meets the minimum standard, even though he or she may have some type of color perception deficiency. If certain color perception tests are administered, (such as Ishihara, Pseudoisochromatic, Yarn) and doubtful findings are discovered, a controlled test using signal red, green and amber may be employed to determine the driver's ability to recognize these colors. Contact lenses are permissible if there is sufficient evidence to indicate that the driver has good tolerance and is well adapted to their use. Use of a contact lens in one eye for distance visual acuity and another lens in the other eye for near vision is not acceptable, nor telescopic lenses acceptable for the driving of commercial motor vehicles. If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner's Certificate: "Qualified only if wearing corrective lenses." CMV drivers who do not meet the Federal vision standard may call (202) for an application for a vision exemption. (See Visual Disorders and Commercial Drivers at: Hearing (b)(11) A person is physically qualified to drive a commercial motor vehicle if that person: First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ADA Standard) Z Since the prescribed standard under the FMCSRs is the American Standards Association (ANSI), it may be necessary to convert the audiometric results from the ISO standard to the ANSI standard. Instructions are included on the Medical Examination report form. If an individual meets the criteria by using a hearing aid, the driver must wear that hearing aid and have it in operation at all times while driving. Also, the driver must be in possession of a spare power source for the hearing aid. For the whispered voice test, the individual should be stationed at least 5 feet from the examiner with the ear being tested turned toward the examiner. The other ear is covered. Using the breath which remains after a normal expiration, the examiner whispers words or random numbers such as 66, 18,