Federal Motor Carrier Safety Administration (FMCSA) Medical Examiner Handbook

Federal Mtr Carrier Safety Administratin (FMCSA) Medical Examiner Handbk

Table f Cntents Intrductin... 7 Part I The Federal Mtr Carrier Safety Administratin (FMCSA)... 8 Abut the FMCSA... 8 FMCSA Missin Statement... 8 Abut the Office f Medical Prgrams... 8 The Office f Medical Prgrams Missin Statement... 8 Abut the Natinal Registry f Certified Medical Examiners... 9 The Natinal Registry f Certified Medical Examiners Missin Statement... 9 The Medical Examiner... 9 Medical Certificatin... 10 Privacy and the Medical Examinatin... 10 Medical Examinatin Reprt Frm... 10 Medical Examiner s Certificate... 11 Medical Regulatins Summary... 11 Cde f Federal Regulatins LAW... 11 Medical Standards/Advisry Criteria/Guidelines... 12 Medical Regulatins Summary Table... 12 Exemptins... 14 Imprtant Definitins... 14 Regulatin Definitins... 14 Part II - The Jb f Cmmercial Driving... 16 FMCSA Regulates Interstate Cmmercial Operatin... 16 Drivers... 16 Vehicles... 16 Truck and Bus Cmpanies... 16 State Regulatins... 17 The Driver and the Jb f Cmmercial Driving... 17 The Driver... 17 The Jb f Cmmercial Driving... 18 FMCSA Cmmercial Driving Facts and Research... 20 Office f Analysis, Research, and Technlgy... 20 Part III - Medical Examinatin Guidelines... 23 Abut 49 CFR 391.43... 23 Purpse f Interstate Cmmercial Driver Physical Examinatin... 23 Driver/Medical Examiner Relatinship... 23 Purpse f Physical Examinatin... 23 The Issue Is Risk... 23 Cnsider Safety Implicatins... 24 Page 2 f 260

Medical Examiner D's... 24 Medical Examinatin Reprt Frm - Overview... 25 Driver Infrmatin... 26 Health Histry... 27 Visin... 33 Hearing... 34 Bld Pressure/Pulse... 36 Urinalysis... 38 Physical Examinatin... 39 Determine Certificatin Status... 43 Certify... 44 Disqualify... 48 Issue Medical Examiner's Certificate... 49 Part IV - Physical Qualificatin Standards and Advisry Criteria... 51 Physical Qualificatin Standards (Regulatins) versus Advisry Criteria (Medical Guidelines)... 51 Onging Standards and Guidelines Review Prcess... 51 Abut 49 CFR 391.41... 52 Visin... 52 Visin Regulatin 49 CFR 391.41(b)(10)... 52 Health Histry and Physical Examinatin... 53 Certificatin and Dcumentatin... 56 Hearing... 59 Hearing Regulatin 49 CFR 391.41(b)(11)... 60 Health Histry and Physical Examinatin... 60 Certificatin and Dcumentatin... 62 Advisry Criteria/Guidance... 63 Hypertensin... 64 Bld Pressure (BP) Regulatins 49 CFR 391.41(b)(6) and 49 CFR 391.43(f)... 65 Health Histry and Physical Examinatin... 65 Advisry Criteria/Guidance... 67 Cardivascular... 73 Cardivascular Regulatin 49 CFR 391.41(b)(4)... 73 Health Histry and Physical Examinatin... 74 Advisry Criteria/Guidance... 75 Respiratry (b)(5)... 117 Respiratry Regulatin 49 CFR 391.41(b)(5)... 118 Health Histry and Physical Examinatin... 118 Advisry Criteria/Guidance... 120 Neurlgical (b)(7)(8)(9)... 136 Page 3 f 260

Neurlgical Regulatins 49 CFR 391.41(b)(7)(8)(9)... 137 Health Histry and Physical Examinatin... 138 Advisry Criteria/Guidance... 140 Musculskeletal (b)(1)(2)(7)... 167 Musculskeletal Regulatins 49 CFR 391.41(b)(1)(2)(7)... 167 Health Histry and Physical Examinatin... 168 Advisry Criteria/Guidance... 170 Diabetes Mellitus... 172 Diabetes Mellitus Regulatin 49 CFR 391.41(b)(3)... 173 Health Histry and Physical Examinatin... 173 Advisry Criteria/Guidance... 175 Other Diseases... 181 Other Diseases Regulatin 49 CFR 391.41(b)(9)... 182 Health Histry and Physical Examinatin... 182 Advisry Criteria/Guidance... 183 Psychlgical Disrders (b)(9)... 185 Psychlgical Regulatin 49 CFR 391.41(b)(9)... 186 Health Histry and Physical Examinatin... 186 Advisry Criteria/Guidance... 189 Drug Abuse and Alchlism... 201 Drug Abuse and Alchlism Regulatins 49 CFR 391.41(b)(12)(13)... 202 Health Histry and Physical Examinatin... 202 Abut 49 CFR 382 Alchl and Drug Rules... 204 Advisry Criteria/Guidance... 205 Medicatins/Drug Use 49 CFR 391.41(b)(12)... 208 Medicatins/Drug Use Regulatin 49 CFR 391.41(b)(12)... 208 Health Histry and Physical Examinatin... 209 Advisry Criteria/Guidance... 211 Appendix A: Medical Examinatin Reprt Frm... 213 Medical Examinatin Reprt Frm - Page 1... 213 Driver Infrmatin... 213 Health Histry... 213 Medical Examinatin Reprt Frm - Page 2... 213 Visin... 213 Hearing... 214 Bld Pressure/Pulse... 214 Urinalysis... 214 Medical Examinatin Reprt Frm - Page 3... 215 Physical Examinatin... 215 Page 4 f 260

Certificatin and Dcumentatin... 215 Appendix B: Federal Exemptin Prgrams... 217 49 CFR 381.300 What is an exemptin?... 217 Federal Visin Exemptin Prgram... 217 Qualified by Operatin f 49 CFR 391.64: "Grandfathered"... 217 Federal Diabetes Exemptin Prgram... 218 Abut the Federal Diabetes Exemptin Prgram... 218 Relevance t Driving... 219 Health Histry and Physical Examinatin... 219 Appendix C: Skill Perfrmance Evaluatin... 223 Fixed Deficit f an Extremity... 223 Appendix D: Cardivascular Recmmendatin Tables... 225 Preface... 225 ANEURYSMS... 226 AORTIC CONGENITAL HEART DISEASE... 227 AORTIC CONGENITAL HEART DISEASE (Cntinued)... 228 AORTIC REGURGITATION... 229 AORTIC STENOSIS... 230 ATRIAL SEPTAL DEFECTS... 231 ATRIAL SEPTAL DEFECTS (Cntinued)... 232 ATRIAL SEPTAL DEFECTS (Cntinued)... 233 BUNDLE BRANCH BLOCKS AND HEMIBLOCKS... 234 CARDIOMYOPATHIES AND CONGESTIVE HEART FAILURE (CHF)... 235 COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD)... 236 COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD) (Cntinued)... 237 COMMERCIAL DRIVERS WITHOUT KNOWN CORONARY HEART DISEASE (CHD)... 238 CONGENITAL HEART DISEASE... 239 CONGENITAL HEART DISEASE (Cntinued)... 240 CONGENITAL HEART DISEASE (Cntinued)... 241 CONGENITAL HEART DISEASE (Cntinued)... 242 CONGENITAL HEART DISEASE (Cntinued)... 243 HEART TRANSPLANTATION... 244 HYPERTENSION... 245 IMPLANTABLE DEFIBRILLATORS... 246 MITRAL REGURGITATION... 247 MITRAL STENOSIS... 248 PACEMAKERS... 249 PACEMAKERS (Cntinued)... 250 PACEMAKERS (Cntinued)... 251 Page 5 f 260

PERIPHERAL VASCULAR DISEASE... 252 SUPRAVENTRICULAR TACHYCARDIAS... 253 SUPRAVENTRICULAR TACHYCARDIAS (Cntinued)... 254 VALVE REPLACEMENT... 255 VALVE REPLACEMENT (Cntinued)... 256 VENOUS DISEASE... 257 VENTRICULAR ARRHYTHMIAS... 258 VENTRICULAR ARRHYTHMIAS (Cntinued)... 259 VENTRICULAR SEPTAL DEFECTS... 260 Page 6 f 260

Intrductin This handbk prvides infrmatin and guidance t the medical examiner wh perfrms the cmmercial driver medical examinatin. Determining driver medical fitness fr duty is a critical element f the FMCSA safety prgram. Specialists, such as cardilgists and endcrinlgists, may perfrm additinal medical evaluatin, but it is the medical examiner wh decides if the driver is medically qualified t drive. Page 7 f 260

Part I The Federal Mtr Carrier Safety Administratin (FMCSA) Abut the FMCSA On December 9, 1999, President Clintn signed int law the Mtr Carrier Safety Imprvement Act f 1999. This act transferred the Office f Mtr Carriers frm the Federal Highway Administratin (FHWA) t establish the Federal Mtr Carrier Safety Administratin (FMCSA). FMCSA is ne f nine U.S. Department f Transprtatin administratins. T learn mre, visit the DOT Agencies Web page at http://www.dt.gv/dotagencies.htm. FMCSA is headquartered in Washingtn, DC and emplys peple in all 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. FMCSA partners and custmers are serviced by field rganizatins. The rganizatins cnsist f Field Operatins, Service Centers, and State-level mtr carrier divisin ffices. FMCSA activities cntribute t ensuring safety in mtr carrier peratins thrugh strng enfrcement f safety regulatins; targeting high-risk carriers and cmmercial mtr vehicle drivers; imprving safety infrmatin systems and cmmercial mtr vehicle technlgies; strengthening cmmercial mtr vehicle equipment and perating standards; and increasing safety awareness. FMCSA Missin Statement "The Federal Mtr Carrier Safety Administratin (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. T learn mre abut FMCSA, visit http://www.fmcsa.dt.gv/abut/abutus.aspx. Abut the Office f Medical Prgrams The Office f Medical Prgrams Missin Statement "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." Page 8 f 260

T prmte safety, the Office f Medical Prgrams: Oversees the natinal medical certificatin prcess fr cmmercial mtr vehicle 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 cmmercial mtr vehicle driver health and safety and cnducts relevant medical research. T learn mre abut the Office f Medical Prgrams, visit http://www.fmcsa.dt.gv/rulesregulatins/tpics/medical/medical.htm. Abut the Natinal Registry f Certified Medical Examiners The Natinal Registry f Certified Medical Examiners Missin Statement "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 Federal Mtr Carrier Safety Administratin standards." FMCSA has begun the rulemaking prcess fr prpsing the Natinal Registry f Certified Medical Examiners (NRCME) prgram. The certified medical examiner wuld: 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. T learn mre abut the Natinal Registry f Medical Examiners, visit https://natinalregistry.fmcsa.dt.gv. The Medical Examiner The Federal Mtr Carrier Safety Regulatins identify a persn wh can be a medical examiner by tw criteria: prfessinal licensure and scpe f practice that includes perfrming physical examinatins. 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. When the Federal Mtr Carrier Safety Administratin (FMCSA) cmpletes the ntice-and-cmment rulemaking fr the prpsed Natinal Registry f Certified Medical Examiners, healthcare prfessinals will be required t be trained and certified and listed n a natinal registry t perfrm physical examinatins f truck and bus drivers. At this time, FMCSA des nt endrse any medical examiner Page 9 f 260

training, educatin r certificatin prgrams, and healthcare prfessinals are nt required t be listed n a registry r ther database t perfrm driver physical examinatins. Medical Certificatin Medical certificatin in accrdance with Federal Mtr Carrier Safety Administratin (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 10,001 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 medical examiner is respnsible fr certifying nly drivers wh meet the physical qualificatin standards. Certificatin cannt exceed 2 years, and at the discretin f the FMCSA medical examiner, may be less than 2 years. The Federal Visin and Diabetes Exemptin Prgrams require annual medical certificatin. The medical examiner's certificate expires at midnight f the day, mnth, and year written n the certificate. There is n grace perid n the expiratin. The driver must be re-examined and recertified t cntinue t drive legally. Privacy and the Medical Examinatin Regulatry requirements take precedence ver the Health Insurance Prtability and Accuntability Act (HIPAA) f 1996. There are ptential subtle interpretatins that can cause significant prblems fr the medical examiner. What infrmatin must r can be turned ver t the carrier is a legal issue, and if in dubt, the examiner shuld btain a legal pinin. Medical Examinatin Reprt Frm Althugh the Federal Mtr Carrier Safety Regulatins d nt require the medical examiner t give a cpy f the Medical Examinatin Reprt frm t the emplyer, the Federal Mtr Carrier Safety Administratin des nt prhibit emplyers frm btaining cpies f the Medical Examinatin Reprt frm. Medical examiners shuld have a release frm signed by the driver if the emplyer wishes t btain a cpy f the Medical 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 http://www.hhs.gv/cr/hipaa/. The HIPAA tll-free infrmatin line is: 1-866-627-7748. Page 10 f 260

Medical Examiner s Certificate 49 CFR 391.43(g) addresses the distributin f the medical examiner s certificate. If the medical examiner finds that the driver is physically qualified t drive a cmmercial mtr vehicle in accrdance with 391.41(b), the medical examiner shall cmplete a medical examiner s certificate and furnish ne cpy t the driver and ne cpy t the mtr carrier that emplys the driver. A release frm is nt required. The mtr carrier is required t keep a cpy f the certificate in the driver qualificatin file. The medical examiner shuld als keep a cpy f the medical examiner's certificate n file. The driver may request a replacement cpy f the certificate frm the medical examiner r get a cpy f the certificate frm the mtr carrier. T view 49 CFR 391.43(g), visit http://www.fmcsa.dt.gv/rulesregulatins/administratin/fmcsr/fmcsrruletext.aspx?reg=391.43#49cfr391.43(g) Figure 1 - Medical Examiner's Certificate 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 "Federal Mtr Carrier Safety Administratin, Department f Transprtatin." Page 11 f 260

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 391.41). When the title is understd, the citatin may just include the part and sectin (e.g., 391.41). Regulatins are law and must be fllwed. Figure 2 - CFR Citatin Medical Standards/Advisry Criteria/Guidelines Standards r Federal Mtr Carrier Safety Regulatins (FMCSRs) are legal requirements fr interstate cmmercial vehicles, drivers, and mtr carriers. FMCSA prvides medical guidelines r 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 t the recmmendatins, the reasn(s) fr nt fllwing the medical guidelines shuld be included in the dcumentatin. Medical Regulatins Summary Table The medical examiner shuld be familiar with the regulatins listed in the fllwing table: Regulatin Descriptin 49 CFR 391.41 Describes the physical qualificatin requirements fr drivers. The 13 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 medical examiner clinical interpretatin. These standards are the "nn-discretinary" standards. Fr the ther nine "discretinary" standards, the medical examiner makes a clinical judgment in accrdance with the physical qualificatin requirements fr driver certificatin. Page 12 f 260

49 CFR 391.43 Describes the respnsibilities f the medical examiner, including general instructins fr perfrming the medical examinatin, a descriptin f driver tasks and wrk envirnment, medical advisry criteria, the sample Medical Examinatin Reprt frm, and the medical examiner's certificate. 49 CFR 391.45 Identifies wh must have the cmmercial mtr vehicle (CMV) driver physical examinatin. 49 CFR 391.47 Describes the prcess fr cnflict reslutin when there is a disagreement between the primary care prvider fr the driver and the medical examiner fr the mtr carrier cncerning driver qualificatins. 49 CFR 391.49 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 391.41(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. Fr mre infrmatin, see Skill Perfrmance Evaluatin Certificatin Prgram (SPE) Histry at http://www.fmcsa.dt.gv/rules-regulatins/tpics/medical/spe-histry.htm. 49 CFR 391.62 Describes limited exemptins fr intra-city zne drivers. 49 CFR 391.64 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 391.64 and cntinue t meet all ther qualificatin standards. 49 CFR 390 Includes general infrmatin and definitins. 49 CFR 40 Includes regulatins fr medical review fficers and substance abuse prfessinals, including drug and alchl testing prcedures. Table 1 - Medical Regulatins Summary Table T view the regulatins in the Medical Regulatins Summary Table, visit: http://www.fmcsa.dt.gv/rulesregulatins/administratin/fmcsr/fmcsrguide.aspx?sectin_type=a. Page 13 f 260

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 medical examiner cannt issue an exemptin. The rle f the medical examiner is t determine if the driver is "therwise qualified." As part f the applicatin prcedure, the driver must btain a medical examinatin, whereby the medical examiner 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. There currently are n FMCSA medical waiver prgrams. Imprtant Definitins Regulatin Definitins The medical examiner shuld becme familiar with frequently used terms in the cntext f the Federal Mtr Carrier Safety Regulatins and the medical examiner rle. Select terms frm 49 CFR 390.5 and 49 CFR 40 fllw. Definitins frm Regulatin 49 CFR 390.5 Cmmercial Mtr Vehicle: 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: Driver: 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. 5103 and transprted in a quantity requiring placarding under regulatins prescribed by the Secretary under 49 CFR, subtitle B, chapter I, subchapter C. 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); Page 14 f 260

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. Intrastate Cmmerce: Intrastate cmmerce means any trade, traffic, r transprtatin in any State which is nt described in the term "interstate cmmerce." Medical Examiner: 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." Fr additinal definitins frm 49 CFR 390.5, visit http://www.fmcsa.dt.gv/rulesregulatins/administratin/fmcsr/fmcsrruletext.asp?rule_tc=759&sectin=390.5&sectin_tc=1739. 49 CFR 40.3 - What D the Terms Used in This Regulatin Mean? The Omnibus Transprtatin Emplyee Testing Act f 1991 requires drug and alchl testing f safetysensitive transprtatin emplyees in aviatin, trucking, railrads, mass transit, pipelines, and ther transprtatin industries. The Department f Transprtatin (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 medical examiner 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. Fr additinal definitins frm 49 CFR 40, visit http://www.dt.gv/st/dapc/new_docs/part40.html?prc. Page 15 f 260

Part II - The Jb f Cmmercial Driving FMCSA Regulates Interstate Cmmercial Operatin The Federal Mtr Carrier Safety Administratin (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 cmmercial mtr vehicle (CMV) drivers are required by law 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. Truck and Bus Cmpanies Mtr carriers, bth fr-hire and private, must cmply with FCMSA regulatins gverning their drivers and minimum levels f financial respnsibility. In the Federal Mtr Carrier Safety Regulatins (FMCSR), 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. Emplyer. Exempt mtr carrier. Mtr carriers are respnsible fr ensuring that the driver meets the general qualificatin requirements f 49 CFR 391.11. The driver must: Be at least 21 years ld. Speak and read English well enugh t: Cnverse with the general public. Understand highway/traffic signals. Respnd t fficial questins. Make legible entries n reprts. Be capable f safely perating the CMV. Page 16 f 260

Have a current Medical Examiner s Certificate n file. Have nly ne valid CMV peratr s license. Have prvided the mtr carrier with required backgrund and vilatins infrmatin. Nt be subject t disqualificatin t drive a CMV under the rules in 49 CFR 391.15. Have successfully cmpleted a driver s rad test r equivalent. Cmmercial driver medical fitness fr duty recrds must include all Federal physical qualificatin requirements fund n the Medical Examinatin Reprt frm. Truck and bus cmpanies may als have additinal medical requirements, such as a minimum lifting capability. The driver culd fail a mtr carrier pre-emplyment driver certificatin examinatin and still meet the Federal physical qualificatin requirements fr certificatin and issuance f a Medical Examiner's Certificate. Stat Regulatins States regulate intrastate cmmerce and cmmercial drivers wh are nt subject t Federal regulatins. They are required, at a minimum, t adpt Federal physical qualificatin requirements and may even have additinal, different, r mre stringent requirements. Medical examiners are respnsible fr knwing the driver regulatins fr the State r States in which they practice. The Driver and the Jb f Cmmercial Driving The Driver Driver Certificatin 49 CFR 391 Qualificatins f drivers and lnger cmbinatin vehicle (LCV) driver instructrs establishes the minimum qualificatins fr persns wh drive a CMV. There are seven subparts. As a medical examiner, yu shuld be knwledgeable regarding the physical qualificatin requirements f the driver specified in Subpart E Physical qualificatins and examinatins. Yu are respnsible fr ensuring that nly the driver wh meets the Federal physical qualificatin requirements is issued a Medical Examiner s Certificate. When yu issue a Medical Examiner s Certificate, yu are certifying that the driver is medically fit fr duty and can perfrm the driver rle that is described in the Medical Examinatin Frm. Yu may certify the driver fr a maximum f 2 years. Yu 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. The driver is respnsible fr maintaining medical certificatin and carrying the Medical 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 cmrbidity. 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. Page 17 f 260

Sedentary. Overweight. Smker. Pr eating habits. The medical prfile: Less healthy than the average persn. Mre than tw medical cnditins. Cardivascular disease prevalent. The Jb f Cmmercial Driving Stress Factrs Assciated with Cmmercial Driving Many factrs cntribute t making cmmercial driving a stressful ccupatin. 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, ff-duty 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 This 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. Page 18 f 260

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. 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 the hand hlds. Hip angle and knee flexin may bth have t exceed 90. Cupling and uncupling the trailers Multiple sub-tasks are perfrmed in the prcess f cupling and uncupling the 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, range f mtin, balance, and flexibility. Page 19 f 260

Lad, secure, and unlad carg Federal Mtr Carrier Safety Administratin (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. FMCSA Cmmercial Driving Facts and Research Office f Analysis, Research, and Technlgy The Federal Mtr Carrier Safety Administratin (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. Page 20 f 260

ART prepares all ecnmic and envirnmental analyses fr FMCSA rulemakings t ensure that changes t mtr carrier regulatins are based n sund data and analysis. Statistics, facts, publicatins, and reprts resulting frm ART studies can be accessed n the FMCSA Web site at http://www.fmcsa.dt.gv/facts-research/art.aspx. Crashes, Injuries, and Fatalities FMCSA is dedicated t lwering the rate f crashes, injuries, and fatalities invlving large trucks and buses. When a fatal crash invlves at least ne large truck, regardless f the cause, the ccupants f passenger vehicles are mre likely t sustain serius injury r die than the ccupants f the large truck. 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 Page 21 f 260

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. Page 22 f 260

Part III - Medical Examinatin Guidelines Abut 49 CFR 391.43 49 CFR 391.43 Medical examinatin; certificate f physical examinatin describes yur respnsibilities as a Federal Mtr Carrier Safety Administratin (FMCSA) medical examiner: determine medical fitness fr duty and issue Medical Examiner's Certificates t cmmercial mtr vehicle (CMV) drivers wh meet the physical qualificatin standards. Visit the FMCSA Medical Prgram Page Link t Respnsibilities f Medical Examiners at http://www.fmcsa.dt.gv/rules-regulatins/tpics/medical/medical.htm. Yu can access 391.43 by ging t the FMCSA Web site, entering "391.43" in the "RULES & REGULATIONS" text bx, and selecting "G." Frm the same area f the Web site, yu can als access 391.43 by selecting the "Medical Prgram" link and then the "Respnsibilities f Medical Examiners" link. Purpsef Interstate Cmmercial Drive 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 medical examiner, yur fundamental bligatin is t establish whether a driver has a disease, disrder, r injury resulting in a higher than acceptable likelihd fr gradual r sudden incapacitatin r sudden death, thus endangering public safety. Driver/Medical Examiner Relatinship Purpse f Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a medical fitness fr duty" examinatin. The Issue Is Risk As a medical examiner, yur fundamental bligatin during the physical assessment is t establish whether a driver has a disease r disrder that interferes with the ability t safely perate a CMV, increases the risk fr sudden death, r increases the risk fr the nset f gradual r sudden incapacitatin, thus endangering public safety. Risk is the prbability f an event ccurring within a certain perid f time. Determining "acceptable risk" is bth a medical and scietal decisin. Page 23 f 260

Des the Driver Pse a Risk t Public Safety? As a medical examiner, any time yu answer yes t this questin, yu shuld nt certify the driver as medically fit fr duty. Cnsider Safety Implicatins Figure 3 - Right t Wrk vs. Public Safety As yu cnduct the physical examinatin t determine if the driver is medically fit t perfrm the jb f cmmercial driving, yu must cnsider: Physical cnditin Symptms Des a benign underlying cnditin with an excellent prgnsis have symptms that interfere with the ability t drive (e.g., a benign supraventricular arrhythmia that causes syncpe)? Incapacitatin Is the nset f incapacitating symptms s rapid that symptms interfere with safe driving, r can the driver stp the vehicle safely befre becming incapacitated? Is the nset f incapacitating symptms s gradual that the driver is unaware f diminished capabilities, thus adversely impacting safe driving? Mental cnditin Cgnitive Can the driver prcess envirnmental cues rapidly and make apprpriate respnses, independently slve prblems, and functin in a dynamic envirnment? Behavir Are the driver interactins apprpriate, respnsible, and nnvilent? Medical treatment Effects Des treatment allw the driver t perfrm tasks safer than withut treatment? Side effects D 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 medical examiner, 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 Page 24 f 260

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 the use f prescriptin and/r ver-the-cunter medicatins. Medicatin warning labels and hw t read them. The imprtance f seeking apprpriate interventin fr nn-disqualifying cnditins, especially thse that, if neglected, culd result in serius illness and pssible future disqualificatin. Medical Examinatin Reprt Frm - Overview As a medical examiner, yu must perfrm the driver physical examinatin and recrd the findings in accrdance with the instructins n the Medical Examinatin Reprt frm. Yu may use an equivalent medical examinatin reprt frm, as lng as all the elements f the Medical Examinatin Reprt frm psted in 49 CFR 391.41 are included. Driver certificatin is determined based n whether r nt the driver meets the requirements f the Federal Mtr Carrier Safety Administratin (FMCSA) physical qualificatin standards cited in 49 CFR 391.41. The purpse f this verview is t familiarize yu with the sectins and data elements n the Medical Examinatin Reprt frm, including, but nt limited t: Organizatin f the frm. Required signatures. Minimum dcumentatin. Part IV Physical Qualificatin Standards elabrates n clinical assessment f driver medical fitness fr duty. Yu are encuraged t have a cpy f the Medical Examinatin Reprt frm fr reference as yu review the remaining tpics. Visit http://www.fmcsa.dt.gv/dcuments/safetyprgrams/medical-reprt.pdf t access a cpy f the Medical Examinatin Reprt frm. Page 25 f 260

Driver Infrmatin The Driver cmpletes sectin 1: Driver Infrmatin Data Fields Figure 4 - Medical Examinatin Reprt Frm: Driver's Infrmatin The driver cmpletes this sectin, but yu, as the medical examiner, must review the data t be sure infrmatin is legible and the sectin is cmpleted. Driver Name (Last, First, Middle) - Verify that the rder is crrect. Scial Security Number (SSN) - Verify the identificatin f the driver. Birthdate (Mnth, Day, Year) - Verify that the rder is crrect. Age - Verify that the birthdate agrees with the age given. NOTE: The mtr carrier is respnsible fr ensuring that the driver meets the 21 years f age requirement befre driving an interstate cmmercial mtr vehicle (CMV). Yu can administer the driver physical t anyne wh requests the examinatin. Sex (Gender) - Self-explanatry. 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 yur driver 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 - Self-explanatry. Telephne Numbers - Self-explanatry. Driver License N., License Class, and State f Issue - Self-explanatry. As a medical examiner, yu are respnsible fr determining medical fitness fr duty and driver certificatin status. Page 26 f 260

The mtr carrier is respnsible fr ensuring that the driver meets the cmmercial driver's license (CDL) requirements befre driving an interstate CMV. Health Histry The Driver cmpletes and signs sectin 2, and the Medical Examiner reviews and adds cmments: Health Histry Driver Instructins Figure 5 - Medical Examinatin Reprt Frm: Health Histry 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 that the Driver signs Medical Examinatin Reprt Frm: Figure 6 - Medical Examinatin Reprt Frm: Driver Signature Page 27 f 260

By signing the Medical 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). Health Histry Medical Examiner 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 cmmercial mtr vehicle (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 driver 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 Medical Examinatin Reprt frm. Fr infrmatin n a specific medical cnditin, see Part IV - Physical Qualificatin Standards f this handbk. Recmmendatins Questins that yu may ask include: Des the driver have: Symptms that interfere with safe driving because f: Frequency? Duratin? Severity? Rapid nset? Limitatins that interfere with safe driving because f: Degree f limitatin present? Likelihd f prgressive limitatin? Medicatins that when used have effects and side effects that interfere with driving ability, such as: Visual disturbances. Drwsiness. Hyptensin. Behaviral changes. Page 28 f 260

Health Histry (Clumn 1) Overview In additin t the guidance prvided in the sectin abve, directins specific t each categry in Clumn 1 fr each "Yes" answer 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. Fr infrmatin n specific medical cnditins, see Part IV f this handbk. 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. 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 nndriving tasks can lead t serius injury f the driver. REMEMBER: The requirements fr screening fr hearing lss are 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 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 perative reprts as cpies f the riginal cardiac catheterizatin reprt, Page 29 f 260

stress tests, wrksheets, and riginal tracings, 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? NOTE: In additin t driving, CMV driver duties include such rigrus activity as cupling and uncupling trailers, lading and unlading trailers, inspecting the vehicle, lifting, installing tire chains, climbing ladders, getting in and ut f the cab, etc. Musculskeletal diseases may adversely impact the CMV driver s muscle strength and agility needed t perfrm these nndriving tasks. 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 nndriving 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 In additin t the guidance prvided in the sectin abve, directins specific t each categry in Clumn 2 are listed belw fr each "Yes" answer. Feel free t ask ther questins t help yu gather sufficient infrmatin t make yur qualificatin/disqualificatin decisin. 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. Page 30 f 260

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 Refer t the guidance fund in Regulatins - Yu must review and discuss with the driver any "Yes" answers. Diabetes r elevated bld glucse cntrlled by diet, pills, r insulin Ask abut treatment, whether by diet, ral medicatins, Byetta, r insulin. REMEMBER: Drivers with insulin-treated diabetes mellitus wh are therwise qualified may apply fr a Federal exemptin. T d s, the medical examiner 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). 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, initial 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 In additin t the guidance prvided in the sectin abve, directins specific t each categry in Clumn 3 are listed belw fr each "Yes" answer. Feel free t ask ther questins t help yu gather sufficient infrmatin t make yur qualificatin/disqualificatin decisin. Fainting, dizziness Nte whether the driver checked Yes due t fainting r 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. Page 31 f 260

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. 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 nndriving 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 Medical Examiner Cmments Overview 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. Page 32 f 260

Visin The Medical Examiner cmpletes sectin 3: Visin Medical Examiner Instructins Figure 7 - Medical Examinatin Reprt Frm: Visin T meet the Federal visin standard, the driver must meet the qualificatin requirements fr visin with bth eyes. Regulatins 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 Use the Snellen chart fr testing r give results in Snellen-cmparable values. Have drivers wh wear crrective lenses fr driving wear crrective lenses fr testing. Evaluate drivers wh wear cntact lenses fr gd tlerance and adaptatin t cntact lens usage. Assess the ability t recgnize and distinguish amng red, amber, and green traffic signals (true clr perceptin deficiencies are rarely disqualifying). If needed, request a visin examinatin by a specialist using advanced visin testing equipment t evaluate driver visin adequately. NOTE: Trained assistive persnnel may perfrm visin screening tests and recrd results. Hwever, the Medical Examiner must sign the Medical Examinatin Reprt frm. By signing the Medical Examinatin Reprt frm, yu are taking respnsibility fr and attesting t the validity f all dcumented test results. Disqualifying Visin Mncular visin. Page 33 f 260

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 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, and State f issue, and sign the examinatin frm. Additinally, ensure that any attached specialist reprt includes all required examinatin and prvider infrmatin listed n the Medical Examinatin Reprt frm. NOTE: Visin is the nly prtin f the driver physical examinatin that can be perfrmed and certified by a prvider ther than a medical examiner. Hearing The Medical Examiner cmpletes sectin 4: Hearing Medical Examiner Instructins Figure 8 - Medical Examinatin Reprt Frm: Hearing T meet the Federal hearing standard, the driver must successfully cmplete ne hearing test with ne ear. Regulatins 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 (see Part IV f this handbk fr mre infrmatin abut Hearing Tests): Frced whisper test. Audimetric test. Page 34 f 260

Cmplete the test in bth ears. If the driver passes the initial hearing test: D nt administer the ther test. Ratinale: test results shw that hearing meets the standard. If the driver fails the initial hearing test: Hearing Aid D administer the ther hearing test. Ratinale: test results frm nly ne test are insufficient t determine whether r nt hearing meets the standard. A driver may use a hearing aid t meet the standard. NOTE: The driver will usually have t g t an audilgist r hearing aid center fr testing with apprpriate equipment because the audimeter used in mst nn-ear-specialty practices is nt designed t test a persn wh is wearing a hearing aid. Recrd use f a hearing aid: 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. NOTE: A driver wh must use a hearing aid t qualify is required t use a hearing aid while driving a cmmercial mtr vehicle (CMV). 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. NOTE: Trained assistive persnnel may perfrm hearing tests and recrd results. Hwever, the Medical Examiner must sign the Medical Examinatin Reprt frm. By signing the Medical Examinatin Reprt frm, yu are taking respnsibility fr and attesting t the validity f all dcumented test results. 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 30 + 33 + 35 = 98/3 = 32.6 = PASS Left ear 40 + 43 + 50 = 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. Page 35 f 260

This driver passed ne hearing test in ne ear. Bld Pressure/Pulse The Medical Examiner cmpletes sectin 5: Figure 9 - Medical Examinatin Reprt Frm: Bld Pressure/Pulse Rate Bld Pressure/Pulse Rate Medical Examiner Instructins Regulatins Yu must measure: Bld Pressure (BP) Pulse 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 Medical Examinatin Reprt frm. Dcument pulse rhythm by marking the Regular r Irregular bx. Recrd pulse rate. Recrd additinal pulse characteristics in yur cmments n the Medical Examinatin Reprt frm. NOTE: Trained assistive persnnel may take and recrd the BP and pulse. 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. Hwever, the Medical Examiner must sign the Medical Examinatin Reprt frm. By signing the Medical Examinatin Reprt frm, yu are taking respnsibility fr and attesting t the validity f all dcumented test results. Bld Pressure/Pulse Rate Stages f Hypertensin Guidelines Table The instructins fr medical examiners fund in 49 CFR 391.43 Bld pressure (BP) stipulate that mre frequent mnitring is apprpriate when a driver has hypertensin at examinatin time r is being medicated fr hypertensin. The Bld Pressure/Pulse Rate sectin f the Medical Examinatin Reprt frm has a table that summarizes the medical guidelines fr BP measurements 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. Page 36 f 260

NOTE: These are recmmendatins. The medical examiner may use his/her clinical expertise and results f the individual driver examinatin t determine the length f time between recertificatin examinatins. Figure 10 - Medical Examinatin Reprt Frm: Bld Pressure/Pulse Rate Recmmendatin Table The fllwing table crrespnds t the first tw clumns f the recmmendatin table in the Medical Examinatin Reprt frm. Clumn ne has the bld pressure readings, and clumn tw has the categry classificatin. Reading Categry 140-159/90-99 Stage 1 hypertensin 160-179/100-109 Stage 2 hypertensin greater than r equal t 180/110 Stage 3 hypertensin Table 2 - Bld Pressure/Pulse Rate Recmmendatin Table Clumns 1 and 2 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 Medical 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 1 year frm date f examinatin if less than r equal t 140/90 6 mnths frm date f examinatin if less than r equal t 140/90 6 mnths if less than r equal t 140/90 Table 3 - Bld Pressure/Pulse Rate Recmmendatin Table Clumns 3 and 4 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. Page 37 f 260

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 cmmercial mtr vehicle (CMV). Urinalysis The Medical Examiner Cmpletes sectin 6: Table 4 - Medical Examinatin Reprt Frm: 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. Prtein (prteinuria). Bld (hematuria). Glucse (glycsuria). NOTE: Trained assistive persnnel may btain urine specimens and recrd test results. Hwever, the Medical Examiner must sign the Medical Examinatin Reprt frm. By signing the Medical Examinatin Reprt frm, yu are taking respnsibility fr and attesting t the validity f all dcumented test results. Additinal Tests and/r Evaluatin frm a Specialist Abnrmal dip stick readings may indicate a need fr further testing. As a medical examiner, yu shuld evaluate the 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 cmmercial mtr vehicle (CMV). Attach any additinal medical reprts btained t the Medical Examinatin Reprt frm. NOTE: Testing fr cntrlled substances is nt a part f the physical qualificatins fr the driver examinatin prcess. Testing fr cntrlled substances falls under a different regulatin. Hwever, if yu suspect a need fr drug/alchl testing, cntact the Federal Mtr Carrier Safety Administratin (FMCSA), r the mtr carrier directly, fr infrmatin n cntrlled substances and alchl testing under Part 382 f the Federal Mtr Carrier Safety Regulatins (FMCSR). Specific questins may be directed t the FMCSA Field Office in yur State r call FMCSA at 1-800-832-5660. Page 38 f 260

Physical Examinatin The Medical Examiner cmpletes sectin 7: Figure 11 - Medical Examinatin Reprt Frm: Physical Evaluatin 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. NOTE: Trained assistive persnnel may measure height and weight. Hwever, the Medical Examiner must sign the Medical Examinatin Reprt frm. By signing the Medical Examinatin Reprt frm, yu are taking respnsibility fr and attesting t the validity f all dcumented test results. Physical Examinatin Medical Examiner 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 ability t perate a cmmercial mtr vehicle (CMV) safely. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (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 Medical 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 Medical Examinatin Reprt frm, even if nt disqualifying. Page 39 f 260

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: Overview 1. General Appearance Observe and nte n the Medical Examinatin Reprt frm any abnrmalities with psture, limps, r tremrs. Als bserve 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. 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 f the ear 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 hearing disrders, such as Meniere's disease, may interfere significantly with driving ability and the perfrmance f ther CMV driver tasks. In this case, guidelines recmmend nt t certify the driver. Page 40 f 260

4. Muth and Thrat Des the cnditin r treatment require lng-term fllw-up and mnitring t ensure that the disease is stabilized, and the treatment is effective and well tlerated? 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 current cardivascular disease accmpanied by and/r likely t cause symptms f syncpe, dyspnea, cllapse, r cngestive cardiac failure? Can the cnditin be crrected surgically r managed well by pharmaclgical treatments? Is the disease prgressive? Des the cnditin r treatment require lng-term fllw-up and mnitring t ensure that the disease is stabilized and treatment is effective and well-tlerated? NOTE: There are n wrk restrictins permitted. The cmmercial driver must be able t perfrm all jbrelated tasks, including lifting, t be certified. 6. Lungs and Chest, Nt Including Breast Examinatin Yu must examine the lungs and chest fr abnrmal chest wall expansin, respiratry rate, and breath sunds including wheezes r alvelar rales. Yu must check fr impaired respiratry functin and cyansis. Be sure t examine the extremities t check 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 additinal pulmnary functin tests and/r have a specialist evaluatin t adequately assess respiratry functin. Bdy System (Clumn 2) CHECK FOR: Overview 7. Abdmen and Viscera Yu must check fr enlarged liver and spleen, masses, bruits, hernia, and significant abdminal wall muscle weakness. Check fr tenderness and auscultate fr bwel sunds. Des an abnrmal finding suggest a cnditin that might interfere with safe CMV peratin? Yu shuld nt make a certificatin decisin until the etilgy is cnfirmed, and treatment has been shwn t be adequate/effective and safe. 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 Page 41 f 260

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 pedals prperly? Des the driver have signs f prgressive musculskeletal cnditins, such as atrphy, weakness, r hyptnia? Des the driver have clubbing r edema that may indicate the presence f an underlying heart, lung, r vascular cnditin? NOTE: If yu find a driver is medically qualified EXCEPT FOR a fixed deficit f an extremity caused by the lss r functinal impairment f a limb, yu can 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). 11. Spine, Other Musculskeletal Yu must check the entire 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 asymmetric? Are patellar reflexes nrmal? Is Babinski's reflex negative r nrmal? Are there any sensry r psitinal abnrmalities? Des an abnrmal finding suggest a cnditin that might interfere with safe CMV peratin? Yu shuld nt make a certificatin decisin until the etilgy is cnfirmed, and treatment has been shwn t be adequate/effective and safe. Page 42 f 260

Determine Certificatin Status Determine Certificatin Status Medical Examiner Respnsibility The Federal Mtr Carrier Safety Administratin (FMCSA) relies n yu, the medical examiner, t assess and determine if the cmmercial mtr vehicle (CMV) driver meets the physical qualificatin requirements cited in 49 CFR 391.41. In sme cases, yu will als cnsider any reprts and recmmendatins frm the primary care prvider and/r specialists treating the driver t supplement yur examinatin and ensure adequate medical assessment. As a medical examiner, yu are respnsible fr making the certificatin decisin and signing the Medical Examinatin Reprt frm. Yu issue a Medical Examiner's Certificate t the drivers yu determine t be medically fit fr duty. Yur certificatin decisin is limited t the certificatin and disqualificatin ptins printed n the Medical Examinatin Reprt frm. The maximum time fr which yu can certify a driver is 2 years. Yu can, hwever, certify fr a perid f time less than 2 years. Certificatin Status When yu determine that a driver is medically fit t drive and als able t perfrm nn-driving respnsibilities, yu will certify the driver and issue a Medical Examiner's Certificate. When yu determine that a driver has a health histry r cnditin that des nt meet physical qualificatin standards, yu must nt certify the driver. Hwever, yu shuld cmplete the examinatin t determine if the driver has mre than ne disqualifying cnditin. Sme cnditins are reversible, and the driver may take actins that will enable him/her t meet qualificatin requirements if treatment is successful. Discussin Regarding Certificatin Decisin Yu must discuss yur certificatin decisin with the driver. Ensure that the driver understands the certificatin decisin. When yu: Certify discussin may include: Reasn fr peridic mnitring and shrtened examinatin interval. Additinal requirements assciated with certificatin. Medical Examiner's Certificate expiratin infrmatin: Occurs at midnight n the expiratin date. Has n grace perid. Disqualify discussin may include: Reasn fr disqualificatin. Steps that can be taken t meet certificatin standards. Temprary disqualificatin. 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. Page 43 f 260

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. Determine Certificatin Status Recrd- keeping Respnsibility Regulatins Yu must dcument the driver physical examinatin Yu must recrd the results f every driver physical examinatin, substantially in accrdance with the Medical Examinatin Reprt frm and the instructins cited in 49 CFR 391.43. Medical Examinatin Reprt Frm Yu are t retain the driver medical recrds fr a minimum f 3 years. Yu will need t prvide a cpy t the driver wh is applying fr, r renewing, a: Skill Perfrmance Evaluatin (SPE) certificate. Diabetes exemptin certificate. Visin exemptin certificate. Medical Examiner's Certificate Prvide the riginal t the driver yu examined and fund medically fit fr duty. Yu must retain a cpy f the driver medical recrds, including the certificate, fr a minimum f 3 years. Yu may prvide a cpy t a prspective r current emplyer upn request. The driver must carry the Medical Examiner's Certificate while perating a CMV. The certificate may be: Certify The riginal certificate. A cpy f the riginal certificate. A reduced-size cpy f the riginal certificate (e.g., wallet size). As a medical examiner, 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 Medical Examinatin Reprt frm and n the Medical Examiner's Certificate. Yu als determine when the driver must repeat the physical examinatin fr cntinuus certificatin. Althugh yu cannt exceed the maximum certificatin perid, 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. Certify Determine Certificatin Interval Overview Regulatins Maximum certificatin 2 years Qualify fr 2- Year Certificate Page 44 f 260

Figure 12 - Medical Examinatin Reprt: 2 Year Certificatin When yur examinatin finds that the driver meets all physical qualificatin standards, yu can certify the driver fr the maximum 2 years. Mark the Meets standards in 49 CFR 391.41; 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) Figure 13 - Medical Examinatin Reprt: Certificatin with Peridic Mnitring Yu will certify fr less than 2 years when a need exists t mnitr the medical fitness fr duty f the driver mre frequently. Sme f the Federal Mtr Carrier Safety Administratin (FMCSA) medical guidelines include recmmendatins fr maximum certificatin intervals 1 year r less. Recmmended maximum certificatin perids are cnsidered best practices. 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. 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. Page 45 f 260

Certify Require Driver t Wear Crrective Lenses and/r Hearing Aid Regulatins Maximum certificatin 2 years with crrective lenses and/r hearing aid Qualify With Requirement t Wear Crrective Sensry Perceptin Device Figure 14 Medical Examinatin Reprt: Certificatin with Requirement t Wear Crrective Sensry Perceptin Device As a medical examiner, yu must specify, as a requirement fr certificatin, that a driver wear crrective lenses and/r a hearing aid when that driver has t use ne r bth t meet the visin and/r hearing physical qualificatin requirements. Mark the Wearing crrective lenses and/r Wearing hearing aid ptin t indicate that the driver must wear the sensry perceptin crrectin device while driving. Yu can cmbine a requirement t wear a sensry perceptin crrectin device with a 2-year certificatin, peridic mnitring certificatin, and/r any f the ther fur listed ptins. Certify Require Driver t Meet Alternate Standard 49 CFR 391.49 Regulatins Maximum certificatin 2 years when driver must meet alternate standard Qualify Skill Perfrmance Evaluatin (SPE) Certificate Figure 15 - Medical Examinatin Reprt: Certificatin When Driver Must Meet Alternate Standard Page 46 f 260

By marking the SPE ptin, yu certify that the driver: Fails t meet ne r mre f the limb requirements f 49 CFR 391.41(b)(1) r (2). Meets all ther physical requirements cited in 49 CFR 391.41(b). Must have bth a valid SPE certificate and Medical Examiner's Certificate t drive. As a medical examiner, 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 Medical Examinatin Reprt frm is required with initial and renewal SPE applicatins. NOTE: The driver with an SPE certificate meets an alternative qualificatin standard fr 49 CFR 391.41(b)(1) r (2). Certify Require Driver T Have a Federal Exemptin Regulatins Maximum certificatin 1 year Qualify With a Federal Exemptin Figure 16 - Medical Examinatin Reprt: Certificatin with 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 cmmercial mtr vehicle (CMV). The Visin Exemptin Prgram allws sme drivers with mncular visin t drive a CMV. T learn mre abut the Federal medical exemptin prgrams, visit http://www.fmcsa.dt.gv/rulesregulatins/tpics/medical/exemptins.htm. As a medical examiner, 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 Medical 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 391.41(b)(3) r the mncular visin requirement f 49 CFR 391.41(b)(10). Meets all ther physical requirements cited in 49 CFR 391.41(b). Must als have a valid Federal medical exemptin certificate t drive. Page 47 f 260

Qualify By Operatin f 49 CFR 391.64 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 391.64, ptin, yu certify that the driver: Presented dcumentatin f participatin in a study. Cntinues t meet 49 CFR 391.64 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 391.62) ptin, yu certify that the driver: Disqualify 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 391.62. As a medical examiner, yu must disqualify the driver wh des nt meet ne r mre f 49 CFR 391.41 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. Disqualify (Des Nt Meet Standards) Figure 17 - Medical Examinatin Frm: Disqualify Page 48 f 260

Dcument the decisin t disqualify n the Medical 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 a medical examiner's certificate. Befre a disqualified driver can return t cmmercial mtr vehicle (CMV) driving, a medical examiner must find the driver t be medically fit fr duty. Disqualify Temprarily Figure 18 - Medical Examinatin Frm: 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 a medical examiner's certificate. REMEMBER: The driver is disqualified and nt allwed t perate a CMV until a medical examiner finds the driver t be medically fit fr duty. Regulatins Medical examiner issues certificate t medically qualified driver When yu find that the driver examined is medically qualified t perate a cmmercial mtr vehicle (CMV) in accrdance with 49 CFR 391.41(b), yu shuld cmplete a certificate as prescribed in 49 CFR 391.43(h) and furnish the riginal t the persn wh was examined. Yu may prvide a cpy t a prspective r current emplyer requesting ne. Issue Medical Examiner's Certificate When yu find that the driver examined is medically qualified t perate a cmmercial mtr vehicle (CMV) in accrdance with 49 CFR 391.41(b), yu shuld cmplete a certificate as prescribed in 49 CFR Page 49 f 260

391.43(h) and furnish the riginal t the persn wh was examined. Yu may prvide a cpy t a prspective r current emplyer requesting ne. Figure 19 - Medical Examiner's Certificate Regulatins Medical examiner issues certificate t medically qualified driver 1. Ensure that the name f the driver matches the name n the Medical Examinatin Reprt frm. 2. Mark any certificatin requirement that applies: wearing crrective lenses wearing hearing aid accmpanied by a waiver r exemptin driving within an exempt intracity zne (49 CFR 391.62) accmpanied by a Skill Perfrmance Evaluatin (SPE) Certificate qualified by peratin f 49 CFR 391.64 3. Write Federal visin r Federal diabetes when exemptin certificate is required. 4. Sign the certificate and cmplete medical examiner infrmatin. 5. Write the date f the medical examinatin. 6. Have the driver sign the certificate and cmpare this with the infrmatin prvided by the driver. 7. Verify that the expiratin date des nt exceed the certificatin interval (maximum certificatin perid is 2 years). Page 50 f 260

Part IV - Physical Qualificatin Standards and Advisry Criteria Physical Qualificatin Standards (Regulatins) versus Advisry Criteria (Medical Guidelines) As a medical examiner, it is imprtant fr yu t distinguish between medical standards and medical guidelines. Regulatins/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 Federal Mtr Carrier Safety Administratin (FMCSA) t prvide yu with 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 cmmercial mtr vehicle (CMV) driver is medically qualified and is safe t drive under the Federal Mtr Carrier Safety Regulatins (FMCSRs). The physical qualificatin regulatins fr CMV drivers in interstate cmmerce are fund at http://www.fmcsa.dt.gv/rulesregulatins/administratin/fmcsr/fmcsrruletext.asp?sectin=391.41#r49cfr391.41-b (Sectin 391.41(b) f the FMCSRs). The advisry criteria under 391.41 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 http://www.fmcsa.dt.gv/rules-regulatins/administratin/medical.htm. Onging Standards and 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. 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 http://www.fmcsa.dt.gv/rules-regulatins/tpics/mep/mep-reprts.htm. Page 51 f 260

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. 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 current standards and guidelines n the FMCSA Medical Prgram Web page at http://www.fmcsa.dt.gv/rulesregulatins/tpics/medical/medical.htm. 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 by FMCSA. Abut 49 CFR 391.41 49 CFR 391.41 Physical qualificatins fr drivers describes the medical fitness fr duty qualificatin standards that an individual must meet in rder t be qualified t perate an interstate cmmercial mtr vehicle (CMV). Yu can access 391.41 n the FMCSA Web site at http://www.fmcsa.dt.gv/ by entering "391.41" in the "RULES & REGULATIONS" text bx, and selecting "G." Frm the same area f the Web site, yu can als access 391.41 by selecting the "Medical Prgram" link and then the "Physical Qualificatins" link. The driver medical qualificatin standards describe requirements that are critical t evaluatin f medical fitness fr duty in cmmercial drivers. 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. Visin 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. Visin Regulatin 4 CF 391.41(b)(10) Regulatin 49 CFR 391.41(b)(10) "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. Page 52 f 260

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 medical examiner, phthalmlgist, r ptmetrist may perfrm and certify visin test results. The medical examiner determines driver certificatin status. Mncular visin is disqualifying. Health Histry and Physical Examinatin Health Histry Here are the visin questins that are asked in the health histry. Yes respnses require clarificatin and dcumentatin. Eye disrders? Impaired visin (d nt include crrective lenses)? Here are imprtant visin questins t ask. Symptms related t r caused by eye diseases? Use f phthalmic preparatins 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. Nte abnrmal findings. Discuss the value f regular visin examinatins in early detectin f eye diseases. Ask abut: Retinpathy. Cataracts. Aphakia. Page 53 f 260

Glaucma. Macular degeneratin. Medical examiners cannt diagnse these diseases r cnditins because mst d nt have the equipment necessary t diagnse them. 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 measures 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 The Snellen chart is widely used fr measuring central visual acuity. The Snellen wall chart shuld be 20 feet away frm the driver. Measure distance. Mark testing lcatin. The chart shuld be illuminated with white light. The driver may wear crrective lenses during the examinatin. When the driver is reading larger lines easily, the medical examiner may ask the driver t skip t smaller lines. Figure 20 - Snellen Chart Snellen chart is illustrative nly and nt suitable fr visin testing Page 54 f 260

Visual Acuity Test Results The Snellen eye test results use 20 feet as the nrm, represented by the numeratr in the Snellen test result. The number f the last line f type the driver read accurately is recrded as the denminatr in the Snellen test result. The minimum qualificatin requirement is distant visual acuity f at least 20/40 in each eye and distant bincular acuity f at least 20/40. Figure 22- Visual Acuity Test Results If a test ther than the Snellen is used t test visual acuity, the test results shuld be recrded in Snellen-equivalent values. Types f Snellen charts There are versins f the Snellen chart that cmpensate fr failure t read letters because f limited English reading skill, nt because f pr eyesight. One example is the "Snellen Eye Chart - Illiterate" that requires the individual t indicate the rientatin f the letter "E" n the chart. Peripheral visin Figure 21 - Snellen Eye Chart Illiterate The requirement fr peripheral visin is at least 70 in the hrizntal meridian fr each eye. In the clinical setting, sme Snellen chart is illustrative nly and frm f cnfrntatinal testing is ften used t evaluate nt suitable fr visin testing peripheral visin. When test results are incnclusive, the evaluatin shuld be perfrmed by a specialist with equipment capable f precise measurements. Prtcl fr Screening the Visual Field The driver must have at least 70 in the hrizntal meridian fr each eye. Sme frm f cnfrntatinal testing that tests visin f selected hrizntal pints is generally used in the clinical setting. A "Prtcl fr Screening the Visual Field Using a Cnfrntatin Methd" is fund in Appendix E f the Visual Requirements and Cmmercial Drivers reprt. Page 55 f 260

Right eye examinatin 1. Stand r sit apprximately tw feet in frnt f the driver s that yur eyes are at abut the same level as the eyes f the driver. 2. Instruct the driver t use the palm f the left hand t cver the left eye. 3. Ask the driver t fixate n yur left eye. 4. Extend yur arms frward and psitin yur hands halfway between yurself and the driver. Psitin yur right hand ne ft t the right f the straight-ahead axis and six inches abve the hrizntal plane. Psitin yur left hand ne-and-a-half feet t the left f the straightahead axis and six inches abve the hrizntal plane. 5. Ask the driver t cnfirm when a mving finger is detected. Repeat the prcedure with yur hands psitined six inches belw the hrizntal meridian. Left eye examinatin Repeat the prcedure fr the left eye (steps 2 thrugh 5), making sure the driver fixates n yur right eye and the hand placement is apprpriately reversed. When test results are incnclusive, btain specialist evaluatin fr precise measurement f peripheral visin. 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 and/r 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. 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 medical examiner may certify the driver fr up t 2 years. The driver wh wears crrective lenses t meet the visin qualificatin requirements must wear crrective lenses while driving. The medical examiner marks the "wearing crrective lenses" checkbx n bth the Medical Examinatin Reprt frm and the medical examiner's certificate. The examiner shuld advise the Page 56 f 260

driver t carry a spare set f eyeglasses. The driver avids bth stress and delay when lst r damaged eyeglasses r uncmfrtable cntact lenses can be replaced immediately. 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. Mncular visin is disqualifying. The medical examiner 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 medical examiner's certificate. 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 Medical Examinatin Reprt frm and the medical examiner's 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. Prvide the driver with a cpy f the Medical Examinatin Reprt. The medical examiner des nt issue a Federal visin exemptin. Bth the medical examiner's certificate and Federal visin exemptin are required befre the driver with mncular visin can legally drive a cmmercial vehicle in interstate cmmerce. See the Federal Visin Exemptin Prgram sectin f this handbk. Ophthalmic Preparatins Determine if the treatment is having the desired effect f preserving visin that meets qualificatin requirements withut any visual and/r systemic side effects that interfere with safe driving (e.g., stinging, blurring, decreased night visin, sensitivity t glare, headache, r allergic reactin). Categries include: Age- related Macular Degeneratin Classificatins f agents used t treat age-related macular degeneratin include: Antixidants and zinc. Vascular endthelial grwth factr (VEGF) inhibitrs. Anti- allergy (Allergic Cnjunctivitis) Classificatins f anti-allergy agents used t treat allergic cnjunctivitis include: Oral and tpical antihistamines. Tpical decngestants. Antihistamine/decngestant cmbinatins. Page 57 f 260

Mast cell stabilizers. Tpical nnsteridal anti-inflammatry. Antiglaucma Agents Classificatins f agents used t treat glaucma include: Prstaglandin analgs. Beta adrenergic blcking agents. Carbnic anhydrase inhibitrs. Alpha agnists. Chlinergic agnists. Osmtic agents. Cmbinatins. Anti- infective Agents (Bacterial Cnjunctivitis) Classificatins f anti-infective agents used t treat bacterial cnjunctivitis include ral and tpical antibitics. Dry Eyes Classificatins f agents used t treat dry eyes include: Lubricants. Nnsteridal anti-inflammatry. Tpical cyclsprine. Ophthalmic Diseases Cataracts Cataracts are a cmmn cause f visual disturbances in the adult ppulatin. The slw, prgressive pacificatin f the crystalline lens f the eye distrts the ptical passage f light t the retina resulting in diminished visual acuity. Cataract frmatin can be accelerated by a number f cnditins, including injury, expsure t radiatin, gut, certain medicatins (sterids), and the presence f diabetes mellitus. Glare, particularly during night driving in the face f ncming headlights, may be an early symptm f cataracts. Glare, diminished verall acuity, cntrast, and clr reslutin are cmpunded by the lightscattering effect f the cataracts. Treatment fr cataracts is surgical remval and placement f an intracular lens. Glaucma Glaucma can cause deficits in peripheral visin. The abnrmal regulatin f intracular pressure can result in gradual prgressive atrphy f ptic nerve cells. The develpment f chrnic elevated intracular pressure is generally painless, and the gradual lss f peripheral visual field can prgress significantly befre symptms are nticed. Glaucma may als affect a number f subtler visual functins, such as redirectin f visual attentin, night visin, and clr visin. With glaucmatus damage, Snellen acuity test results may nt be affected, but peripheral field test results may shw deficits. Specialist examinatin may result in early detectin and treatment befre the ccurrence f pssibly disqualifying visin lss. Page 58 f 260

Visin lss caused by glaucma cannt be restred. A therapeutic gal is t lwer intracular pressure t a level that preserves the existing neurnal cells and prevents further lss f the peripheral visual field deficit. Strict and nging cmpliance with prescribed phthalmic preparatins is required fr successful treatment; hwever, antiglaucma agents may have side effects that impact visin and interfere with safe driving. Macular Degeneratin Macular degeneratin is a leading cause f untreatable legal blindness in the United States. Macular degeneratin describes many phthalmic diseases that impact the macula functin and interfere with detailed, central visin. These diseases increase in prevalence with age, affecting sme 30% f all Americans by age 70. Fr the majrity f cases, macular degeneratin is a slw prcess resulting in subtle visual defects; hwever, apprximately 10% f cases are a "malignant" frm f the disease and cause rapid lss f central visin. Peripheral visin is generally spared in macular degeneratin. Therapeutic ptins are limited. Macular degeneratin causes nticeable signs and symptms. Visual acuity drps, recvery frm bright lights is lengthened, and eventually a partial r ttal sctma develps in the directin f attempted gaze. Snellen-type acuity testing will detect diminishing central acuity. Telescpic lenses redirect unaffected peripheral visin t cmpensate fr lst central acuity, resulting in a reduced peripheral field f visin. The use f telescpic lenses is nt acceptable fr cmmercial driving. Retinpathy Nninflammatry damage t the retina f the eye has many causes. The mst cmmn cause f retinpathy is diabetes mellitus. Backgrund retinpathy with micraneurysms and intraretinal hemrrhages is cmmn after 5-7 years with diabetes mellitus. In many cases, the retinpathy des nt prgress beynd this stage; hwever, fluid leakage near the macula (diabetic macular edema) can create partial sctmas in central visin r cause grss hemrrhage in the eye which can bscure visin and eventually lead t retinal detachment and blindness. Subtler visual mdalities such as cntrast sensitivity, flicker fusin frequency, and clr discriminatin may als be affected. Strict cntrl f bld glucse, as well as medical cntrl f cmrbid diseases (e.g., hypertensin, renal disease, cardiac disease), may prevent r delay develpment f retinpathy. Medical guidelines fr the driver with diabetes mellitus include: Annual medical examinatin. Annual phthalmlgist r ptmetrist eye evaluatin. Disqualificatin fr a diagnsis f unstable prliferative retinpathy. Other diseases can cause retinpathy. Carcinma-assciated retinpathy is characterized by rapid nset f blindness caused by retinal degeneratin, usually f phtreceptrs. Prliferative retinpathy can be a cmplicatin f sickle cell disease and sickle cell-thalassemia disease. A rare but characteristic finding f systemic lupus erythematsus is retinal exudates, usually near the disk. Hearing 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. Page 59 f 260

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. Hearing Regulatin 4 CF 391.41(b)(11) "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) Z24.5 1951." 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. Health Histry and Physical Examinatin Health Histry Here are the hearing questins that are asked in the health histry. Yes respnses require clarificatin and dcumentatin. Ear disrders? Lss f hearing? Lss f balance? Here are imprtant questins t ask. Symptms related t r caused by ear disease? Use f tic preparatins? Page 60 f 260

Physical Examinatin Examine the ears fr: Scarring f the tympanic membranes. 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 is required. Frced whisper test First perceives a frced whispered vice. In ne ear. At nt less than five feet. A hearing aid may be wrn while testing. When a hearing aid is used t qualify, the hearing aid must be wrn while driving. The testing area shuld be free frm nise that culd interfere with a valid test. Measure and mark the five-ft passing distance. Right Ear Examinatin: 1. Have the driver cver the left ear. 2. Stand t the side r behind the driver t eliminate visual cues. 3. Frm the measured five-ft distance frm the right ear, exhale fully and then whisper a sequence f wrds, numbers, r letters. (Avid using nly s-sunding wrds.) 4. Ask the driver t repeat the whispered sequence. 5. T pass, the driver must respnd crrectly. Left Ear Examinatin: Repeat the prcedure fr the left ear, making sure that the right ear is cvered and that yu are psitined the measured five-ft distance frm the left ear. Cmplete the frced whisper test fr bth ears, whether r nt the initial test result meets the hearing requirement. Page 61 f 260

Audimetric Test The hearing qualificatin requirement fr the 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. The hearing requirement fr an audimetric test is based n hearing lss nly at the 500 Hz, 1,000 Hz, and 2,000 Hz frequencies that are typical f nrmal cnversatin. The test results are fr an audimeter calibrated t the American Natinal Standards Institute (ANSI) Z24.5-1951 standard. When an audimeter that is calibrated t a different standard is used, the test results must be cnverted t the ANSI standard. T cnvert Internatinal Organizatin fr Standardizatin (ISO) test results t the ANSI standard, subtract frm the ISO test results: 14 db fr 500 Hz, 10 db fr 1,000 Hz, and 8.5 db fr 2,000 Hz. The area selected fr testing shuld be free frm nise that culd interfere with a valid test. 1. Recrd hearing test results fr each ear at 500 Hz, 1,000 Hz, and 2,000 Hz (ANSI standard). 2. Average the readings fr each ear by adding the test results and dividing by 3. 3. T pass, ne ear must shw an average hearing lss that is less than r equal t 40 db. Hearing aid When a hearing aid is t be wrn during audimetric testing, an audilgist r hearing aid center shuld perfrm the test using apprpriate audimetric equipment. Additinal Evaluatin and/r 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. 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 medical examiner 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 medical examiner marks the "wearing hearing aid" checkbx n bth the Medical Examinatin Reprt frm and the medical examiner's certificate. The examiner shuld advise the driver t carry a spare pwer surce fr the hearing aid. Page 62 f 260

Advisry Criteria/Guidance Otic Preparatins Determine if the treatment is having the desired effect f preserving hearing, reducing inflammatry disrders causing pain, and/r cntrlling dizziness causing lss f balance. Determine if the treatment has any effects and/r side effects that interfere with safe driving (e.g., drug, fd, and/r alchl interactins, excessive drwsiness, r allergic reactin). Categries include: Anti- acute Benign Psitinal Vertig Classificatins f agents used t treat acute vertig include: Antihistaminic antiemetics. Benzdiazepines. Antichlinergics. Sympathmimetics. Anti- infective/anti- inflammatry Agents Infectin and inflammatin can be f the external auditry canal (EAC) and/r the middle ear. Classificatins f tpical drps used t treat EAC include: Antibitics. Sterids. Antibitic-sterid cmbinatins. Classificatin f ral drugs used t treat infectins and inflammatin f the middle ear (titis media) include: Antibitics. Sterids. Otic Disease and Cnditins Meniere's Disease The Cnference n Neurlgical Disrders and Cmmercial Drivers reprt recmmends disqualificatin when there is a diagnsis f Meniere's disease. Vertig Vertig is generally caused by an inner ear abnrmality. Uncntrlled vertig is disqualifying. The Cnference n Neurlgical Disrders and Cmmercial Drivers reprt recmmends that the driver may be certified after cmpleting at least 2 mnths symptm free with a diagnsis f: Benign psitinal vertig. Acute and chrnic peripheral vestibulpathy. Page 63 f 260

Labyrinthine Fistula The Cnference n Neurlgical Disrders and Cmmercial Drivers reprt recmmends disqualificatin when there is a diagnsis f labyrinthine fistula. Nnfunctining Labyrinth The Cnference n Neurlgical Disrders and Cmmercial Drivers reprt recmmends disqualificatin when there is a diagnsis f nnfunctining labyrinth. T review the Cnference f Neurlgical Disrders and Cmmercial Drivers reprt, visit: http://www.fmcsa.dt.gv/facts-research/research-technlgy/publicatins/medreprts.htm. Hypertensin 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 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, cmmercial mtr vehicle (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 10-20 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. Cntemprary medical therapies are effective in lwering BP, reducing cmplicatins, and are generally regarded as safe. Page 64 f 260

Bld Pressure (BP) Regulatins 4 CF 391.41(b)(6) an 4 CF 391.43(f) 49 CFR 391.41(b)(6) "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 391.43(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 160/100-179/109) 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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect 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. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a fitness fr duty" examinatin. As the medical examiner, yur fundamental bligatin is t establish whether a driver has high BP that is likely t interfere with the ability t perate a CMV safely, thus endangering public safety. The examinatin is based n infrmatin prvided by the driver (histry), bjective data (measuring BP and physical examinatin), and additinal testing requested by the medical examiner. Yur 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. Key Pints fr High BP/Hypertensin Medical Examinatin During the physical examinatin, yu shuld ask the same questins that yu wuld fr any individual wh is being assessed fr high BP and/r with a current clinical diagnsis f hypertensin. 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 FMCSA Medical 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 Medical 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. Page 65 f 260

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. Regulatins Yu must review and discuss with the driver any "yes" answers Des the driver: Have high BP? Take medicatin? Recmmendatins Questins that yu may ask include 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 Yu must evaluate 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. Measure Bld Pressure and Check Pulse Measure Bld Pressure Because f the prevalence f hypertensin in the cmmercial driving ppulatin, this rutine test is an essential tl as part f the physical examinatin t determine the medical fitness fr duty f the driver. Bld pressure (BP) shuld be measured in a standardized fashin using equipment that meets certificatin criteria. BP levels aid in evaluating the risk f an acute hypertensive event while driving and assist yu as yu make certificatin decisins that allw a driver wh des nt present an immediate safety risk t cntinue wrking while btaining primary care prvider evaluatin and implementing a primary care prvider treatment plan. REMEMBER: Yu are the medical examiner and nt the treating prvider. The purpse f the examinatin is medical fitness fr duty, nt diagnsis and treatment f the underlying disease. NOTE: Under the supervisin f the medical examiner, trained assistive persnnel may measure and recrd BP; hwever, it is prudent fr the medical examiner t cnfirm disqualifying BP persnally. Page 66 f 260

Check Pulse Check the pulse and nte rate, strength, and rhythm. Cnfirm Elevated BP Cnfirm BP higher than r equal t 140/90 with a secnd measurement taken later during the examinatin. BP, especially systlic pressure, will fluctuate in a shrt time frm nrmal t elevated and back t nrmal as a respnse t many factrs, including: Circadian cycle. Emtinal and physical states. Transient hypertensin (e.g., "white cat syndrme"). Use f left versus right arm during BP measurement. Prblems with technique, such as: Placing the BP cuff ver clthing instead f n the skin. Using an inapprpriately-sized BP cuff. Psitining the arm incrrectly. Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including if available: Onset date and diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin used while driving, including ver-the-cunter medicatins. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr. Overall requirements fr cmmercial drivers as well as the specific requirements in the jb descriptin f the driver shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Essential Hypertensin The Sixth Reprt f the Jint Natinal Cmmittee n Preventin, Detectin, Evaluatin, and Treatment f High Bld Pressure established three stages f hypertensin that define the severity f hypertensin and guide therapy. T review the reprt, visit: http://www.ncbi.nlm.nih.gv/bks/nbk8632/. 49 CFR 391.43(f) Bld Pressure (BP) was amended t include the use f BP readings equivalent t the stages f hypertensin t determine driver certificatin status. The cmplete text f the amendment may be accessed at http://www.fmcsa.dt.gv/rules-regulatins/administratin/rulemakings/03-24736miscellaneus-amendments09-30-03.pdf. Page 67 f 260

When yu determine certificatin fr the driver with high BP in the ranges f stage 1 r stage 2 hypertensin (BP greater than 140/90 but less than 180/100), cnsider these additinal factrs: Type f examinatin (certificatin r recertificatin). Current certificatin interval (1-2 years r 3 mnths). Treatment (lifestyle changes, use f medicatin). Severity f hypertensin prir t treatment (particularly if histry f stage 3 hypertensin). The purpse f the ne-time, 3-mnth certificate is t allw the driver with high BP that is an abslute indicatin fr antihypertensive drug therapy t cntinue t drive while taking steps t lwer the elevated BP. It is nt intended as a means t indefinitely extend driving privileges fr a driver with a cnditin that is assciated with lng-term risks. Fr the driver with high BP r hypertensin t maintain cntinuus certificatin, the driver must demnstrate at examinatin BP at r less than 140/90. NOTE: "One-time" means yu cannt issue cnsecutive 3-mnth certificates fr BP greater than 140/90. It des nt mean nce in a lifetime. Stage 1 Hypertensin Stage 1 hypertensin is usually asymptmatic, and bld pressure (BP) in this range is cnsidered a lw risk fr hypertensin-related acute incapacitatin. Hwever, all hypertensive drivers shuld be strngly encuraged t pursue cnsultatin with a primary care prvider t ensure apprpriate therapy and healthcare educatin. BP measurement greater than r equal t 140/90 and less than 160/100. Waiting perid N recmmended time frame NOTE: The driver wh is disqualified fr the presence f high BP/uncntrlled hypertensin shuld nt be cnsidered fr recertificatin until the BP is stabilized at less than r equal t 140/90. Treatment shuld be well tlerated befre cnsidering certifying a driver with a histry f stage 3 hypertensin. Decisin Maximum certificatin perid 1 year OR ne time fr 3 mnths Recmmend t certify fr 1 year if: It is the first examinatin at which the driver has BP equivalent t stage 1 hypertensin and the driver: Has n histry f hypertensin. Des nt use antihypertensive medicatin t cntrl BP. Recmmend t certify ne time fr 3 mnths if: The driver has: A 1-year certificate fr untreated stage 1 hypertensin. Nt been prescribed antihypertensive medicatin t cntrl high BP. Page 68 f 260

This applies t the recertificatin f the driver wh has met the first examinatin 1-year certificatin parameters. Advise the driver that failure t lwer BP t less than r equal t 140/90 will render the driver medically unqualified fr cntinued certificatin. The driver: Has a diagnsis f hypertensin treated with medicatin. Tlerates treatment with n side effects that interfere with driving. This applies t the driver with inadequately cntrlled BP. Advise the driver that failure t lwer BP t less than r equal t 140/90 will render the driver medically unqualified fr cntinued certificatin. Recmmend nt t certify if: The driver has: A ne-time, 3-mnth certificate fr elevated BP r hypertensin and BP greater than 140/90. A histry f stage 3 hypertensin and BP greater than 140/90. BP greater than r equal t 180/110, regardless f any ther cnsideratins. NOTE: "One-time" means yu cannt issue cnsecutive 3-mnth certificates fr BP greater than 140/90. It des nt mean nce in a lifetime. Mnitring/Testing The driver wh is disqualified fr stage 1 hypertensin may be recertified fr 1 year if BP is lwered t less than 140/90. The driver wh is disqualified fr stage 3 hypertensin may be recertified fr 6 mnths if BP is lwered t less than 140/90 and medicatins are well tlerated. Fllw- up The driver with elevated BP r hypertensin shuld have at least an annual medical examinatin. When certified fr 3 mnths, the driver is t seek initiatin r evaluatin f drug therapy t lwer BP t less than r equal t 140/90 t be recertified at fllw-up examinatin. T review the Hypertensin Recmmendatin Table, see Appendix D f this handbk. REMEMBER: When determining certificatin fr the driver with high BP r hypertensin, take int cnsideratin current driver certificatin status, use f antihypertensive medicatin, and severity f hypertensin prir t treatment. Stage 2 Hypertensin Stage 2 hypertensin is cnsidered an abslute indicatin fr antihypertensive drug therapy, and the driver shuld seek initiatin r evaluatin f therapy t lwer bld pressure (BP). Effective BP management includes rutine primary prvider fllw-up and peridic screens fr the presence f target rgan damage and clinical manifestatins f cardivascular disease. BP measurement greater than r equal t 160/100 and less than 180/110. Page 69 f 260

Waiting perid N recmmended time frame NOTE: The driver wh is disqualified fr high BP/uncntrlled hypertensin shuld nt be cnsidered fr recertificatin until the BP is stabilized at less than r equal t 140/90. Treatment shuld be well tlerated befre cnsidering certifying a driver with a histry f stage 3 hypertensin. Decisin Maximum certificatin perid One time fr 3 mnths Recmmend t certify if: It is the first examinatin at which the driver has BP equivalent t stage 2 hypertensin and the driver: Has n histry f hypertensin. Des nt use antihypertensive medicatin t cntrl BP. The driver: Has a diagnsis f hypertensin treated with medicatin. Tlerates treatment with n side effects that interfere with driving. NOTE: Advise the driver issued a ne-time, 3-mnth certificate that: T qualify at fllw-up, BP shuld be at r less than 140/90. If the driver at fllw-up qualifies, a 1-year certificate will be issued frm the date f the initial examinatin, nt the expiratin date f the ne-time, 3-mnth certificate. If the driver fails t lwer BP by the expiratin date f the ne-time, 3-mnth certificate, the driver will be disqualified until BP is at r less than 140/90 at examinatin. Recmmend nt t certify if: The driver has: A ne-time, 3-mnth certificate fr stage 2 hypertensin and BP greater hypertensin and BP greater than 140/90. A histry f stage 3 hypertensin and BP greater than 140/90. BP greater than r equal t 180/110, regardless f any ther cnsideratins. Mnitring/Testing Prvided treatment is well tlerated and the driver demnstrates BP f 140/90 r less, the driver may be certified fr 1 year frm the date f the initial examinatin. Fllw- up The driver must fllw-up n r befre the ne-time, 3-mnth certificate expiratin date. If the driver has BP less than r equal t 140/90, the driver may be certified fr 1 year. NOTE: The elapsed time f the ne-time, 3-mnth certificate is included in the annual certificatin interval; it is nt an extensin t the certificatin perid. This means that yu use the date n the ne- Page 70 f 260

time, 3-mnth certificate t calculate the medical certificate expiratin date. D nt use the date f the fllw-up examinatin at which the driver demnstrates adequate BP. NOTE: "One-time" means yu cannt issue cnsecutive 3-mnth certificates fr BP greater than 140/90. It des nt mean nce in a lifetime. REMEMBER: When determining certificatin fr the driver with high BP r hypertensin, take int cnsideratin current driver certificatin status, use f antihypertensive medicatin, and severity f hypertensin prir t treatment. Stage 3 Hypertensin Stage 3 hypertensin carries a high risk fr the develpment f acute hypertensin-related symptms that culd impair judgment and driving ability. Acute manifestatins f elevated bld pressure (BP) can include sudden strke, acute pulmnary edema, subarachnid hemrrhage, artic dissectin, r artic aneurysm rupture. Meningismus, acute neurlgical deficits, abrupt nset f shrtness f breath, r severe, ripping back r chest pain culd signal an impending hypertensive catastrphe that requires immediate cessatin f driving and emergency medical care. Symptms f hypertensive urgency such as headache and nausea are likely t be mre subtle, subacute in nset, and mre amenable t treatment than a hypertensive emergency. BP measurement greater than r equal t 180/110. Waiting perid Nt applicable. Decisin Maximum certificatin perid 6 mnths with histry f stage 3 hypertensin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has BP equal t stage 3 hypertensin, regardless f histry r treatment. NOTE: The driver is at risk fr an acute hypertensive event and shuld be advised t seek, r shuld be prvided immediate medical attentin and must be medically disqualified. Mnitring/Testing Befre the driver wh is disqualified fr stage 3 hypertensin can be cnsidered fr recertificatin (maximum 6 mnths), the driver must, at examinatin have: BP at r less than 140/90. Treatment that is well tlerated. At future semi-annual examinatins, if BP is equivalent t stage 1 r stage 2 hypertensin, n a case-bycase basis, yu shuld determine the apprpriate use f the ne-time, 3-mnth certificate in accrdance with stage 1 r stage 2 hypertensin guidelines. Page 71 f 260

If yu believe BP greater than 140/90 at rest indicates an unacceptable risk fr develpment f stage 3 hypertensin and the nset f acute hypertensin-related symptms, yu may temprarily disqualify the driver until BP is at r less than 140/90 and treatment is well tlerated. Fr example, when maximum dses f multiple antihypertensive medicatins are used withut achieving BP at r less than 140/90, it is prudent that a mre aggressive treatment plan shuld be mnitred fr effectiveness, interactins, and tlerance prir t driver certificatin. Fllw- up The driver shuld have a medical examinatin at least every 6 mnths. REMEMBER: When determining certificatin fr the driver with high BP r hypertensin, take int cnsideratin current driver certificatin status, use f antihypertensive medicatin, and severity f hypertensin prir t treatment. Secndary Hypertensin The prevalence f secndary hypertensin in the general ppulatin is estimated at between 5% and 20%. Yu shuld btain infrmatin that assesses the underlying cause, the effectiveness f treatment, and any side effects that may interfere with driving. Examples f primary cnditins that may lead t secndary hypertensin include phechrmcytma, primary aldsternism, renvascular disease, and unilateral renal parenchymal disease. Sme f these cnditins may be amenable t surgical interventin. Waiting perid Minimum 3 mnths pst-surgical crrectin NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year pst-surgical crrectin NOTE: Determine nnsurgically repaired secndary hypertensin using the essential hypertensin guidelines. Recmmend t certify if: The driver has bld pressure that is less than r equal t 140/90. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. Page 72 f 260

Cardivascular The 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. 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. Cardivascular Regulatin 4 CF 391.41(b)(4) "A persn is physically qualified t drive a cmmercial mtr vehicle (CMV) 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." Page 73 f 260

Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect driver ability t perate a CMV safely. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a medical fitness fr duty" examinatin. As the medical examiner, yur fundamental bligatin during the cardivascular assessment is t establish whether a driver has a cardivascular disease r disrder that increases the risk fr sudden death r incapacitatin, thus endangering driver and public safety and health. The examinatin is based n infrmatin prvided by the driver (histry), bjective data (physical examinatin), and additinal testing requested by the medical examiner. Yur 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. Key Pints fr Cardivascular Examinatin During the physical examinatin, yu shuld ask the same questins yu wuld f any individual wh is being assessed fr cardivascular cncerns. The FMCSA Medical Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins shuld be asked t supplement infrmatin requested n the frm. Yu shuld ask abut and dcument cardivascular symptms. Regulatins Yu must review and discuss with the driver any "Yes" answers 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 that yu may ask include: Des the driver have: Chest pain? Chest pressure r ache with exertin? Pain, pressure, r dyspnea at rest r with exertin? Recurrent and/r severe palpitatins? Page 74 f 260

Pre-syncpe (dizziness, light-headedness) r true syncpe (lss f cnsciusness)? Medical therapy that requires mnitring? Recrd Regulatins Yu must evaluate: On examinatin, des the driver have: Murmurs, extra heart sunds, r arrhythmias? An enlarged heart? Abnrmal pulse and amplitude, cartid r arterial bruits, r varicse veins? Remember Regulatins Yu must dcument discussin with the driver abut: Any affirmative histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal cardivascular tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr. Overall requirements fr cmmercial drivers, as well as the specific requirements in the jb descriptin f the driver, shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Anticagulant Therapy The mst current guidelines fr the use f warfarin (Cumadin) fr cardivascular diseases are fund in the Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Anticagulant therapy may be utilized in the treatment f cardivascular r neurlgical cnditins. The guidelines emphasize that the certificatin decisin shuld be based n the underlying medical disease r disrder requiring medicatin, nt the medicatin itself. Waiting perid Minimum 1 mnth stabilized Page 75 f 260

NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is stabilized n medicatin fr at least 1 mnth. Prvides a cpy f the internatinal nrmalized rati (INR) results at the examinatin. Has at least mnthly INR mnitring. Recmmend nt t certify if: INR is nt being mnitred. INR is nt therapeutic. Underlying disease is disqualifying. Mnitring/Testing The driver shuld btain INR mnitring at least mnthly. Fllw- up The driver shuld bring results f INR mnitring t the examinatin. Waiting perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a cerebrvascular disrder. NOTE: The ratinale fr disqualificatin is the high rate f cmplicatins assciated with bleeding that can incapacitate the driver while perating a vehicle. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Cardivascular Tables Archive Visit http://www.fmcsa.dt.gv/dcuments/cardi.pdf t review the Cardivascular Tables Archive. Page 76 f 260

Aneurysms, Peripheral Vascular Disease, and Venus Disease and Treatments The diagnsis f arterial disease shuld alert yu t the need fr an evaluatin t determine the presence f ther cardivascular diseases. Rupture is the mst serius cmplicatin f an abdminal artic aneurysm and is related t the size f the aneurysm. Deep venus thrmbsis can be the surce f acute pulmnary embli r lead t lng-term venus cmplicatins. Intermittent claudicatin is the primary symptm f peripheral vascular disease f the lwer extremities. Abdminal Artic Aneurysm The majrity f abdminal artic aneurysms (AAAs) ccur in the sixth and seventh decades f life and ccur mre frequently in males than in females by a 3:1 rati. The majrity f AAAs are asymptmatic. An AAA can be assciated with ther cardivascular disease. The verall detectin rate f AAAs n examinatin is 31%. Detectin during a physical examinatin depends n aneurysm size and is affected by besity. Clinical examinatin identifies apprximately 90% f aneurysms greater than 6 cm. Auscultatin f an abdminal bruit may indicate the presence f an aneurysm. Risk f rupture Rupture is the mst serius cmplicatin f an AAA and can be life threatening. The risk f rupture increases as the aneurysm increases in size. An AAA: Less than 4 cm rarely ruptures. Smaller than 5 cm has a 1% t 3% per year rate f rupture. 5 cm t 6 cm has a 5% t 10% per year rate f rupture. Greater than 7 cm has apprximately a 20% per year rate f rupture. Mnitring f an aneurysm is advised because the grwth rate can vary and rapid expansin can ccur. Waiting perid Minimum 3 mnths fr pst-surgical repair f an aneurysm NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The AAA is: Less than 4 cm and the driver is asymptmatic. Greater than 4 cm but less than 5 cm and the driver is asymptmatic and has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Surgically repaired and the driver meets pst-surgical repair f aneurysm guidelines. Recmmend nt t certify if: Page 77 f 260

The driver has: Symptms, regardless f AAA size. Recmmendatin fr surgical repair, regardless f AAA size, frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. The AAA: Is greater than 4 cm but less than 5 cm and driver des nt have medical clearance fr cmmercial driving frm a cardivascular specialist. Is greater than r equal t 5 cm. Has increased mre than 0.5 cm during a 6 mnth perid, regardless f size. Mnitring/Testing Ultrasund has almst 100% sensitivity and specificity fr detecting an AAA and is recmmended t mnitr change in size. Fllw- up The driver shuld have an annual medical examinatin. T review the Aneurysm Recmmendatin Table, see Appendix D f this handbk. Acute Deep Vein Thrmbsis The cmmercial driver is at an increased risk fr develping acute deep vein thrmbsis (DVT) due t lng hurs f sitting as part f the prfessin. DVT can be the surce f pulmnary embli that can cause gradual r sudden incapacitatin r death. Adequate treatment with anticagulants decreases the risk f recurrent thrmbsis by apprximately 80%. Waiting perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed, and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has n residual, acute DVT. Recmmend nt t certify if: The driver has DVT ineffectively treated. Mnitring/Testing When DVT treatment includes anticagulant therapy, the driver shuld meet mnitring guidelines. Fllw- up The driver shuld have an annual medical examinatin. Page 78 f 260

T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Chrnic Thrmbtic Venus Disease Chrnic thrmbtic venus disease f the legs increases the risk f pulmnary embli; hwever, there is insufficient research t cnfirm the level f risk. As a medical examiner, yu must evaluate n a case-bycase basis t determine if the driver meets cardivascular requirements. Waiting perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin perid 2 years Recmmend t certify if: The driver has n symptms. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have a biennial medical examinatin. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Intermittent Claudicatin Apprximately 7% t 9% f persns with peripheral vascular disease develp intermittent claudicatin, the primary symptm f bstructive vascular disease f the lwer extremity. In cases f severe arterial insufficiency, necrsis, neurpathy, and atrphy may ccur. Waiting perid Minimum 3 mnths fr pst-surgical repair Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Page 79 f 260

Recmmend t certify if: The driver, fllwing surgery has: Relief f symptms. N ther disqualifying cardivascular disease. Recmmend nt t certify if: The driver has pain at rest. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. T review the Peripheral Vascular Disease Recmmendatin Table, see Appendix D f this handbk. Other Aneurysms Aneurysms can develp in visceral and peripheral arteries and venus vessels. Rupture f any f these aneurysms can lead t gradual r sudden incapacitatin and death. Much f the infrmatin n artic aneurysms is applicable t aneurysms in ther arteries. Waiting perid Minimum 3 mnths pst-surgical repair f an aneurysm NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver has: Surgical repair f the aneurysm and meets pst-surgical repair f aneurysm guidelines. Clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Recmmendatin fr surgical repair f an aneurysm, frm a cardivascular specialist wh understands the functins and demands f cmmercial driving, but has nt had surgical repair. Page 80 f 260

Mnitring/testing Yu may, n a case-by-case basis, btain additinal tests and cnsultatins t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. T review the Aneurysm Recmmendatin Table, see Appendix D f this handbk. Peripheral Vascular Disease Aneurysms can develp in visceral and peripheral arteries and venus vessels. Rupture f any f these aneurysms can lead t gradual r sudden incapacitatin and death. Much f the infrmatin n artic aneurysms is applicable t aneurysms in ther arteries. Waiting perid Minimum 3 mnths pst-surgical repair f an aneurysm NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver has: Surgical repair f the aneurysm and meets pst-surgical repair f aneurysm guidelines. Clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Recmmendatin fr surgical repair f an aneurysm, frm a cardivascular specialist wh understands the functins and demands f cmmercial driving, but has nt had surgical repair. Mnitring/Testing Yu may, n a case-by-case basis, btain additinal tests and cnsultatins t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. T review the Aneurysm Recmmendatin Table, see Appendix D f this handbk. Page 81 f 260

Pst- Surgical Repair f Aneurysm With imprved surgical utcmes, and withut cntraindicatin fr surgery, aneurysms can be electively repaired t prevent rupture. The decisin by the treating prvider nt t surgically repair an aneurysm des nt mean that the driver can be certified t drive safely. Hwever, a recmmendatin t surgically repair an aneurysm disqualifies the driver until the aneurysm has been repaired and a satisfactry recvery perid has passed. Waiting perid Minimum 3 mnths pst-surgical repair NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is asymptmatic. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Recmmendatin fr surgical repair f an aneurysm frm a cardivascular specialist wh understands the functins and demands f cmmercial driving, but has nt had surgical repair. Mnitring/Testing When pst-surgical treatment includes anticagulant therapy, the driver shuld meet mnitring guidelines. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Fllw- up The driver shuld have an annual medical examinatin. T review the Aneurysm Recmmendatin Table, see Appendix D f this handbk. Pulmnary Embli Deep vein thrmbsis can be ne f the surces f pulmnary embli (PE). PE can cause gradual r sudden incapacitatin and significant mrbidity and mrtality. Waiting perid Minimum 3 mnths with n pulmnary emblism Page 82 f 260

NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Apprpriate lng-term treatment. N ther disqualifying cardivascular disease. Recmmend nt t certify if: The driver has symptms. Mnitring/Testing When PE treatment includes anticagulant therapy, the driver shuld meet mnitring guidelines. Fllw- up The driver shuld have an annual medical examinatin. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Superficial Phlebitis Althugh superficial phlebitis is a benign and self-limited disease, deep vein thrmbsis (DVT) is ften a cexisting cnditin and needs t be excluded during the curse f examinatin. Waiting perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin perid 2 years Recmmend t certify if: The driver is therwise medically qualified. Recmmend nt t certify if: The driver has cexisting DVT and des nt meet the DVT guidelines. Page 83 f 260

Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have a biennial medical examinatin. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Thracic Aneurysm While relatively rare, thracic aneurysms are increasing in frequency. Size f the arta is cnsidered the majr factr in determining risk fr dissectin r rupture f a thracic aneurysm. Waiting perid Minimum 3 mnths pst-surgical repair NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Has a thracic aneurysm less than 3.5 cm. Has a surgically repaired thracic aneurysm and the driver meets pst-surgical repair f aneurysm guidelines, including: Has cmpleted surgical repair waiting perid. Has medical clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has a thracic aneurysm greater than 3.5 cm. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. T review the Aneurysm Recmmendatin Table, see Appendix D f this handbk. Page 84 f 260

Varicse Veins Varicse veins with the assciated symptms and cmplicatins affect mre than 20 millin peple in the United States. Cmplicatins include chrnic venus insufficiency, leg ulceratins, and recurrent deep vein thrmbsis. The presence f varicse veins des nt medically disqualify the cmmercial driver. Waiting perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin perid 2 years Recmmend t certify if: The driver has n cmplicatins. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have a biennial medical examinatin. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Cardiac Arrhythmias and Treatment The majrity f sudden cardiac deaths are thught t be secndary t ventricular tachycardia r ventricular fibrillatin and ccur mst ften when there is n prir diagnsis f heart disease. Risk determinatin is difficult because f the number f variables that must be cnsidered. The prgnsis is generally determined by the underlying heart disease. While defibrillatin may restre a nrmal rhythm, there remains a high risk f recurrence. When the driver has a histry f arrhythmia r uses an anti-arrhythmia device, yu, as a medical examiner, shuld cnsider the fllwing: Is the underlying heart disease disqualifying? What is the risk fr sudden death? What is the risk fr cerebral hypperfusin and lss f cnsciusness? Page 85 f 260

Implantable Cardiverter- Defibrillatrs Implantable cardiverter-defibrillatrs (ICD) are electrnic devices that treat cardiac arrest, ventricular fibrillatin, and ventricular tachycardia thrugh the delivery f rapid pacing stimuli r shck therapy. ICDs treat but d nt prevent arrhythmias. Therefre, the driver remains at risk fr syncpe. The management f the underlying disease is nt effective enugh fr the driver t meet cardivascular qualificatin requirements. Cmbinatin ICD/pacemaker devices are als ineffective in preventing incapacitating cardiac arrhythmia events. Waiting perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has an: ICD. ICD/pacemaker cmbinatin device. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. T review the Implantable Defibrillatr Recmmendatin Table, see Appendix D f this handbk. Pacemakers A pacemaker is an implantable device designed t treat bradycardia. When assessing the risk fr sudden, unexpected incapacitatin in a driver with a pacemaker, the underlying disease respnsible fr the pacemaker indicatin must be cnsidered. Bth sinus nde dysfunctin and atriventricular (AV) blck have variable lng-term prgnses, depending n the underlying disease. Cerebral hypperfusin is usually crrected by supprt f heart rate via the implantatin f a pacemaker. Currently, pacemakers and the lead systems are reliable and durable ver the lng term. Waiting perid Minimum 1 mnth pst-pacemaker implantatin if underlying disease is: Sinus nde dysfunctin. AV blck. Page 86 f 260

Minimum 3 mnths pst-pacemaker implantatin if underlying disease is: Neurcardigenic syncpe. Hypersensitive cartid sinus with syncpe. NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Dcumentatin indicating the presence f a functining pacemaker. Dcumentatin indicating cmpletin f rutine pacemaker checks. N disqualifying underlying disease. Recmmend nt t certify if: The driver has: An implantable cardiac defibrillatr/pacemaker cmbinatin device. A disqualifying underlying disease. Mnitring/Testing The driver shuld: Cmply with pacemaker center scheduled functin checks. Prvide dcumentatin f pacemaker functin checks at examinatin. Fllw- up The driver shuld have an annual medical examinatin. T review the Pacemaker Recmmendatin Table, see Appendix D f this handbk. Supraventricular Arrhythmias Supraventricular arrhythmias fall int tw main categries: supraventricular tachycardia (SVT) and atrial fibrillatin. Supraventricular tachycardia SVT is a cmmn arrhythmia that is usually nt cnsidered a risk fr sudden death. On ccasin, SVT can cause lss f cnsciusness r cmprmise cerebral functin. Treatment by catheter ablatin is usually curative and allws drug therapy t be withdrawn. Atrial fibrillatin Page 87 f 260

The majr risk assciated with atrial fibrillatin is the presence f an emblus which can cause a strke. Anticagulant therapy decreases the risk f peripheral emblizatin in individuals with risk factrs fr strke. See the Supraventricular Tachycardias Recmmendatin Table fr diagnsis-specific recmmendatins. The fllwing are general recmmendatins. Waiting perid Minimum 1 mnth anticagulated adequately and diagnsis is atrial fibrillatin As cause f strke r risk fr strke. Fllwing thracic surgery. Minimum 1 mnth pst-isthmus ablatin and diagnsis is atrial flutter Minimum 1 mnth asymptmatic/treated asymptmatic and diagnsis is: Atriventricular ndal reentrant tachycardia. Atriventricular reentrant tachycardia and Wlff-Parkinsn-White syndrme. Atrial tachycardia. Junctinal tachycardia. NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Heart rate that is cntrlled. Treatment fr preventin f embli that is effective and tlerated. N underlying disease that is disqualifying. Clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The cnditin causes: Lss f cnsciusness. Cmprmised cerebral functin. Sudden death resuscitatin. Page 88 f 260

Mnitring/Testing The driver shuld: Cmply with anticagulant therapy guidelines, when apprpriate. Have annual evaluatin by a cardivascular specialist wh understands the functins and demands f cmmercial driving. Fllw- up The driver shuld have an annual medical examinatin. REMEMBER: There are times when the medical assessment and the guidelines may yield different cnclusins abut the severity f the cnditin. A driver culd have a benign underlying medical prblem with an excellent prgnsis but still nt be medically qualified as a cmmercial driver. Fr example, if a benign supraventricular arrhythmia causes syncpe, the driver cannt be medically certified until the prblem has been crrected. Ventricular Arrhythmias Ventricular arrhythmias are categrized as ventricular fibrillatin and ventricular tachycardia and are respnsible fr the majrity f instances f cardiac sudden death. Mst cases are caused by crnary heart disease, but can als ccur in peple with hearts that are structurally nrmal. Certificatin parameters include: Left ventricular ejectin fractin (LVEF). Nnsustained ventricular tachycardia (NSVT). Ventricular tachycardia (VT). See the Ventricular Arrhythmias Recmmendatin Table in Appendix D f this handbk fr diagnsisspecific recmmendatins. Waiting perid Minimum 1 mnth after drug r ther therapy and diagnsis is: Crnary heart disease. Right ventricular utflw VT. Idipathic left ventricular VT. NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is asymptmatic. Page 89 f 260

Has an identified nn-disqualifying cardiac cause. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver: Is symptmatic. Has sustained VT. Has NSVT, LVEF less than 0.40. Has a diagnsis f: Hypertrphic cardimypathy. Lng QT interval syndrme. Brugada syndrme. Mnitring/Testing Have annual evaluatin by a cardivascular specialist wh understands the functins and demands f cmmercial driving. Fllw- up The driver shuld have an annual medical examinatin. See the Ventricular Arrhythmias Recmmendatin Table fr diagnsis-specific recmmendatins. Cardivascular Tests Detectin f an undiagnsed heart r vascular finding during a physical examinatin may indicate the need fr further testing and examinatin t adequately assess medical fitness fr duty. Diagnstic-specific testing may be required t detect the presence and/r severity f cardivascular diseases. The additinal testing may be rdered by the medical examiner, primary care physician, cardilgist, r cardivascular surgen. 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 descriptin f the rle f the driver and a cpy f the applicable medical standard(s) and guidelines with the request. Recrd additinal tests in the Medical Examinatin Reprt frm, Sectin 6. LABORATORY AND OTHER TEST FINDINGS, and/r attach additinal test reprts. Echcardigraphy Figure 23 - Medical Examinatin Reprt Frm: Labratry and Other Test Findings Left ventricular ejectin fractin (LVEF) may be assessed by echcardigraphy. Imaging studies have superir sensitivity and specificity cmpared t the standard exercise tlerance test (ETT) and are indicated in the presence f an abnrmal resting electrcardigram r nn-diagnstic standard ETT. Page 90 f 260

Driver shuld have: An LVEF greater than r equal t 40%. N pulmnary hypertensin. NOTE: Pulmnary hypertensin is pulmnary artery pressure greater than 50% f systemic systlic bld as determined by echcardigraphy r cardiac catheterizatin. REMEMBER: If echcardigraphy test results are incnclusive, sme frm f radinuclide imaging may be used t btain the ejectin fractin measurement. Exercise Tlerance Test The exercise tlerance test is the mst cmmn test used t evaluate wrklad capacity and detect cardiac abnrmalities. Driver shuld be able t: Exercise t a wrklad capacity greater than 6 Metablic Equivalents (METs) (thrugh Bruce prtcl stage II r equivalent). Attain a heart rate greater than r equal t 85% f predicted maximum (unless n beta blckers). Have a rise in systlic bld pressure greater than r equal t 20 mm Hg withut angina. Have n significant ST segment depressin. NOTE: METs Extensive literature exists n the energy requirements fr many physical tasks. Sedentary activity requires fewer than 2 METs. These activities include sitting, slw walking, and lifting light bjects f n mre than 10 punds. Light wrk requires 2 t 4 METs and includes carrying lightweight bjects f n mre than 20 punds. Medium wrk requires 4 t 6 METs and includes carrying mderate weight bjects f up t 50 punds. Heavy and very heavy wrk requires greater than 6 METs and includes carrying heavy bjects and climbing stairs rapidly. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus wrk. Overall requirements fr cmmercial drivers alng with the specific requirements in the jb descriptin shuld be deciding factrs in the certificatin prcess. Cardivascular Recmmendatin Tables See Appendix D f this handbk. Crnary Heart Diseases and Treatments As a medical examiner, it is yur decisin whether the nature and severity f the cnditin f the driver will result in gradual r sudden incapacitatin. The majr clinical manifestatins f crnary heart disease (CHD) are acute mycardial infarctin, angina pectris (either stable r unstable), cngestive heart failure, and sudden death. Page 91 f 260

Sudden death ccurs when an individual ges frm a usual state f health t death within 1 hur. In sme cases, thse wh suffer sudden death are asymptmatic with the first symptm f CHD being sudden death. The incidence f crashes caused by sudden death is relatively lw, primarily because f the length f time between the nset f the cardivascular event and the incapacitatin f the driver. Therefre, it is imprtant that yu educate the driver abut warning signs f an impending CHD event. Emphasize that the driver may have nly a shrt time fllwing the nset f symptms t safely stp the vehicle and call fr medical assistance. Prgnstic indicatrs fr CHD The majr predictr f CHD is left ventricular functin. Other indicatrs t be cnsidered include: General heath. Age. Arrhythmias. Angina pectris. Assciated vascular disease. Severity f CHD. General CHD recmmendatin summary The qualified driver with CHD shuld: Secure clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Tlerate cardivascular medicatin and be: Knwledgeable abut medicatins used while driving. Free frm side effects that cmprmise driving ability. Cmpliant with the nging treatment plan. Acute Mycardial Infarctin The first few mnths fllwing an acute mycardial infarctin (MI) pse the greatest risk f mrtality, with the majrity f deaths classified as sudden death. Current pinin amng clinicians states that pst-mi drivers may safely return t any ccupatinal task prvided there is n exercise-induced mycardial ischemia r left ventricular dysfunctin. Waiting Perid Minimum 2 mnths NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Page 92 f 260

Is asymptmatic. Tlerates medicatins. Has a satisfactry exercise tlerance test (ETT). Has a resting left ventricular ejectin fractin (LVEF) greater than r equal t 40%. Has n electrcardigram ischemic changes. NOTE: Fr an initial certificatin fllwing an MI, an in-hspital pst-mi echcardigram shwing an LVEF greater than r equal t 40% is sufficient. Recmmend nt t certify if: The driver has: Rest angina r change in angina pattern within 3 mnths f examinatin. Ischemic changes n rest electrcardigram (ECG). Intlerance t cardivascular therapy. Mnitring/Testing The driver shuld btain: Clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Biennial ETT. NOTE: Drivers in a rehabilitatin prgram can receive cmprehensive secndary preventin therapy. Fllw- up The driver shuld have an annual medical examinatin. T review the Cmmercial Drivers With Knwn CHD Recmmendatin Tables, see Appendix D f this handbk. Angina Pectris Angina pectris is at the lwer end f the spectrum fr risk f adverse clinical utcmes amng individuals with crnary heart disease (CHD). The presence f this cnditin usually implies that at least ne crnary artery has hemdynamically significant narrwing. When evaluating the driver with angina, yu shuld distinguish between stable and unstable angina. The presence f unstable angina may be a precursr t a cardivascular episde knwn t be accmpanied by syncpe, dyspnea, cllapse, r cngestive cardiac failure. Stable angina May be precipitated by a predictable pattern, including: Exertin. Emtin. Page 93 f 260

Extremes in weather. Sexual activity. Unstable angina Has an unpredictable curse characterized by: Pain ccurring at rest. Changes in pattern (i.e., increased frequency and lnger duratin). Decreased respnse t medicatin. Waiting Perid Minimum 3 mnths with n rest angina r change in angina pattern NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Has stable angina. Is asymptmatic. Tlerates medicatins. Has a satisfactry exercise tlerance test (ETT). Recmmend nt t certify if: The driver has had unstable angina within 3 mnths f examinatin. Mnitring/Testing The driver shuld btain: Evaluatin frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Biennial ETT. NOTE: If an ETT is incnclusive, an imaging stress test may be indicated. Fllw- up The driver shuld have an annual medical examinatin. T review the Cmmercial Drivers With Knwn CHD Recmmendatin Tables, see Appendix D f this handbk. Page 94 f 260

CHD Risk- Equivalent Multiple CHD Risk Factrs The presence f ne r mre f these medical cnditins may be insufficient t nt certify a driver. Hwever, the presence f these cnditins can cause the driver t be at as great a risk f sudden death r incapacitatin as the driver with knwn crnary heart disease (CHD). CHD risk-equivalent cnditins include: Presence f diabetes mellitus. Presence f peripheral vascular disease. A Framingham risk scre predicting a 20% CHD event risk ver the next 10 years. T view the Framingham Heart Study, visit: http://www.nhlbi.nih.gv/guidelines/chlesterl/risk_tbl.htm. Being ver 45 years f age with multiple risk factrs fr CHD. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. NOTE: The decisin nt t medically certify a cmmercial driver shuld nt depend slely n the detectin f multiple risk factrs. Mnitring/Testing The driver shuld btain: Onging treating prvider fllw-up. Aggressive cmprehensive risk factr management. Fllw- up The driver shuld have an annual medical examinatin. T review the Cmmercial Drivers Withut Knwn CHD Recmmendatin Tables, see Appendix D f this handbk. Page 95 f 260

Crnary Artery Bypass Grafting Crnary artery bypass grafting (CABG) surgery is frequently the preferred chice f therapy fr individuals with multi-vessel crnary heart disease, narrwing f the prximal left main crnary artery, and extensive athersclersis in the presence f left ventricular dysfunctin r debilitating angina. Fllwing CABG surgery, individuals are at less risk f sudden death than thse wh are treated medically. Mst drivers wh underg CABG surgery are able t return t wrk. A lnger waiting perid is recmmended t allw sternal incisin healing. The sternum shuld be cmpletely healed befre certifying a driver. A significant risk assciated with CABG surgery is the high lng-term recclusin rate f the bypass graft. Waiting Perid Minimum 3 mnths regardless f type f CABG surgery perfrmed NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is asymptmatic. Tlerates cardivascular medicatins with n rthstatic symptms. Has a left ventricular ejectin fractin (LVEF) greater than r equal t 40%. Is examined and apprved by a cardilgist fr medical fitness t drive. Has a healed sternum. Recmmend nt t certify if: The driver: Is symptmatic. Has rthstatic symptm side effects frm cardivascular medicatin. Has an LVEF less than 40%. Is examined and is nt apprved by a cardilgist fr medical fitness t drive. Has a sternum that has nt healed. Mnitring/Testing Because f the risk f recclusin ver time, 5 years pst-cabg surgery, the driver shuld btain: Annual exercise tlerance test. Imaging stress test, if indicated. Page 96 f 260

Fllw- up The driver shuld have an annual medical examinatin. T review the Cmmercial Drivers With Knwn CHD Recmmendatin Tables, see Appendix D f this handbk. Heart Failure Crnary artery bypass grafting (CABG) surgery is frequently the preferred chice f therapy fr individuals with multi-vessel crnary heart disease, narrwing f the prximal left main crnary artery, and extensive athersclersis in the presence f left ventricular dysfunctin r debilitating angina. Fllwing CABG surgery, individuals are at less risk f sudden death than thse wh are treated medically. Mst drivers wh underg CABG surgery are able t return t wrk. A lnger waiting perid is recmmended t allw sternal incisin healing. The sternum shuld be cmpletely healed befre certifying a driver. A significant risk assciated with CABG surgery is the high lng-term recclusin rate f the bypass graft. Waiting Perid Minimum 3 mnths regardless f type f CABG surgery perfrmed NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is asymptmatic. Tlerates cardivascular medicatins with n rthstatic symptms. Has a left ventricular ejectin fractin (LVEF) greater than r equal t 40%. Is examined and apprved by a cardilgist fr medical fitness t drive. Has a healed sternum. Recmmend nt t certify if: The driver: Is symptmatic. Has rthstatic symptm side effects frm cardivascular medicatin. Has an LVEF less than 40%. Is examined and is nt apprved by a cardilgist fr medical fitness t drive. Has a sternum that has nt healed. Page 97 f 260

Mnitring/Testing Because f the risk f recclusin ver time, 5 years pst-cabg surgery, the driver shuld btain: Annual exercise tlerance test. Imaging stress test, if indicated. Fllw- up The driver shuld have an annual medical examinatin. T review the Cmmercial Drivers With Knwn CHD Recmmendatin Tables, see Appendix D f this handbk. Percutaneus Crnary Interventin The Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers recmmendatins fr percutaneus crnary interventin (PCI) encmpass angiplasty and ther catheter-based techniques aimed at relieving crnary bstructins. In the setting f an uncmplicated, elective prcedure t treat stable angina, the pst-prcedure waiting perid is 1 week. The waiting perid allws fr a small threat caused by acute cmplicatins at the vascular access site. Drivers underging PCI in the setting f an acute mycardial infarctin r unstable angina shuld be restricted frm driving duties fr the lnger waiting perid recmmended fr these cnditins. Waiting Perid Minimum 1 week NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is asymptmatic at examinatin. Tlerates medicatins. Has n injury t the vascular access site. NOTE: Initially certify fr up t 6 mnths. Recertify fr up t 1 year if exercise tlerance test (ETT) results are satisfactry. Page 98 f 260

Recmmend nt t certify if: The driver has: Incmplete healing r cmplicatin at vascular access site. Rest angina. Ischemic electrcardigram (ECG) changes. Mnitring/Testing NOTE: Fllwing initial certificatin, the driver shuld have an ETT 3 t 6 mnths pst-percutaneus crnary interventin and bring results t a 6-mnth fllw-up examinatin. The driver shuld btain: Clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Biennial ETT. NOTE: If an ETT is incnclusive, an imaging stress test may be indicated. Fllw- up The driver shuld have an annual medical examinatin. NOTE: Delayed restensis is the majr PCI limitatin and requires intensive secndary preventin. Typical angina symptms shuld prmpt evaluatin with a stress imaging study r repeat angigraphy. T review the Cmmercial Drivers With Knwn CHD Recmmendatin Tables, see Appendix D f this handbk. Cngenital Heart Disease Heart failure and sudden death are the majr causes f death amng individuals with cngenital heart disease. Due t the cmplexity f these prblems, the Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Drivers recmmend that the driver has regular, nging fllwup by a cardilgist knwledgeable in adult cngenital heart disease. The driver with cngenital heart disease must meet the qualificatin standards. As a medical examiner, yur decisin t certify shuld be based n: Anatmic diagnsis. Severity f the cngenital defect. Results f treatment. Present fitness status. Risk f sudden death r incapacitatin. Cngenital Heart Disease Recmmendatin Table (PDF) Page 99 f 260

NOTE: The Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers discusses multiple cngenital heart diseases, many f which are self-limiting. Advances in surgical and medical management are expected t result in an increased number f individuals with cngenital heart disease seeking driver certificatin. Ebstein anmaly is included in the handbk because it is a cnditin yu are likely t encunter in the clinical setting. Ebstein Anmaly Ebstein anmaly is a cngenital dwnward displacement f the tricuspid valve. The natural histry f the patient with Ebstein anmaly depends n its severity. Adults with a mild frm f Ebstein anmaly can remain asymptmatic thrughut their lives. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver: Is asymptmatic. Has a mild tricuspid anmaly. Has mild cardiac enlargement. Has mild right ventricular dysfunctin. Recmmend nt t certify if: The driver has a(n): Mderate r severe anmaly. Intracardiac lesin. Shunt. Symptmatic arrhythmia. Accessry cnductin pathway. Mnitring/Testing Annual cardivascular re-evaluatin shuld include echcardigraphy and evaluatin by a cardilgist knwledgeable in adult cngenital heart disease and wh understands the functins and demands f cmmercial driving. Fllw- up The driver shuld have an annual medical examinatin. T review the Cngenital Heart Disease Recmmendatin Table, see Appendix D f this handbk. Page 100 f 260

Heart Transplantatin Althugh the number f heart transplant recipients is relatively small, sme recipients may wish t be cmmercial mtr vehicle drivers. The majr medical cncerns fr certificatin f a cmmercial driver heart recipient are transplant rejectin and pst-transplant athersclersis. Waiting Perid Minimum 1 year pst transplant NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 6 mnths Recmmend t certify if: The driver: Is asymptmatic. Tlerates medicatins. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Has n signs f transplant rejectin. Meets all ther qualificatin requirements. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin endangers the health and safety f the driver and the public. Mnitring/Testing Mnitring the driver with a heart transplant shuld include re-evaluatin and recertificatin every 6 mnths by a cardivascular specialist wh: Is an expert in the fields f cardilgy and transplant medicine. Understands the functins and demands f cmmercial driving. Evaluates the pssibility f athersclersis, the status f the transplant, and the general health f the driver. Fllw- up The driver shuld have a medical examinatin every 6 mnths. T review the Heart Transplantatin Recmmendatin Table, see Appendix D f this handbk. Hypertensin See the Hypertensin sectin f this handbk. Page 101 f 260

Mycardial Disease Mycardial diseases are ften prgressive and require lng-term fllw-up. Even s, imprved diagnstic testing and treatment can increase the number f drivers with mycardial disease wh seek cmmercial mtr vehicle driver certificatin. Hypertrphic Cardimypathy Hypertrphic cardimypathy is a cmplex disease characterized by marked mrphlgic, genetic, and prgnstic hetergeneity. Sme individuals experience a benign and stable clinical curse, while in thers the disease is characterized by prgressive symptms. Fr sme individuals, sudden death is the first definitive manifestatin f the disease. Waiting Perid If yu nte an enlarged heart in a driver, yu shuld nt certify the driver until evaluatin by a cardivascular specialist wh understands the functins and demands f cmmercial driving t cnfirm r rule ut a diagnsis f hypertrphic cardimypathy. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f hypertrphic cardimypathy. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. T review the Cardimypathies and Cngestive Heart Failure Recmmendatin Table, see Appendix D f this handbk. Restrictive Cardimypathy The May Clinic perfrmed a study n idipathic restrictive cardimypathy between 1979 and 1996. The Clinical Prfile and Outcme f Idipathic Restrictive Cardimypathy reprt indicated a 5-year survival rate f nly 64%, cmpared with an expected survival rate f 85%. Waiting Perid If yu suspect restrictive cardimypathy in a driver, yu shuld nt certify the driver until evaluatin by a cardivascular specialist wh understands the functins and demands f cmmercial driving t cnfirm r rule ut a diagnsis f restrictive cardimypathy. Decisin Recmmend t certify if: Nt applicable. Page 102 f 260

Recmmend nt t certify if: The driver has a diagnsis f restrictive cardimypathy. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. T review the Cardimypathies and Cngestive Heart Failure Recmmendatin Table, see Appendix D f this handbk. Syncpe Syncpe is a symptm, nt a medical cnditin, that can present an immediate threat t public safety when causing the driver f a cmmercial mtr vehicle t lse cntrl f the vehicle. As an example, syncpe as a cnsequence f an arrhythmia while driving, places the driver and thers arund the driver at the time in serius jepardy. Medicatins are available that are effective in managing ventricular arrhythmias and, althugh they are designed t prevent ccurrences, they are nt "fail-safe" and if an arrhythmia recurs, syncpe may fllw. Recurrent, unexplained syncpe and syncpe frm cardiac causes may herald a markedly increased future risk fr sudden death. As a medical examiner, yu shuld ensure that: Diagnsis distinguishes between pre-syncpe (i.e., dizziness, lightheadedness) and true syncpe (i.e., lss f cnsciusness). The medicatins used by the driver d nt predispse the driver t precipitus declines in bld pressure, syncpe, fatigue, r electrlyte shifts and imbalances. Cardiac-based syncpe is differentiated frm ther causes f syncpe. Cnductin system diseases that cause syncpe must be treated befre the driver is cnsidered fr certificatin. Other frms f syncpe, such as neurlgical-based cnditins (e.g., migraine headache, seizures) are adequately evaluated. Yu may refer t the Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers fr diagnsis-specific recmmendatins fr: Hypersensitive cartid sinus with syncpe. Neurcardigenic syncpe. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Page 103 f 260

Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Has been treated fr symptmatic disease. Is asymptmatic. Tlerates medicatins. Is at lw risk fr syncpe/near syncpe. Has clearance frm an apprpriate specialist (e.g., cardilgist, neurlgist) wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver: Experiences syncpe as a cnsequence f the disease prcess, regardless f the underlying cnditin. Is at high risk fr syncpe/near syncpe, regardless f the underlying heart disease and/r treatment. NOTE: Distinguish between treatments that reduce the risk fr syncpe and treatments where the driver remains at risk fr syncpe. Certificatin als depends n the risk fr syncpe and gradual r sudden incapacitatin frm the underlying heart disease that may remain even after successful treatment f the cnductin system disease. Mnitring/Testing The driver shuld: Cmply with medicatin and/r treatment guidelines, when apprpriate. Have annual evaluatin by a cardivascular specialist wh understands the functins and demands f cmmercial driving (refer t diagnsis-specific recmmendatins). Fllw- up The driver shuld have an annual medical examinatin. See the Supraventricular Tachycardias Recmmendatin Table and Pacemakers Recmmendatin Table in Appendix D f this handbk fr diagnsis-specific recmmendatins. Valvular Heart Diseases and Treatments Murmurs are a cmmn sign f valvular heart cnditins; hwever the presence f a murmur may be assciated with ther cardivascular cnditins. As a medical examiner, yu must distinguish between functinal murmurs and pathlgical murmurs that are medically disqualifying. Page 104 f 260

Classificatin f Murmur Severity The intensity f murmurs is classified n a scale f I t VI, frm the least prnunced murmur t the ludest. Classificatin is rated as fllws: Grade I Must strain t hear a murmur. Grade II Can hear a faint murmur withut straining. Grade III Can easily hear a mderately lud murmur. Grade IV Can easily hear a mderately lud murmur that has a thrill. Grade V Can hear the murmur when nly part f the stethscpe is in cntact with the skin. Grade VI Can hear the murmur with the stethscpe clse t the skin; it des nt have t be in cntact with the skin t detect the murmur. Murmurs that are: Systlic and grade I r II are usually benign if the driver has n signs r symptms f heart disease. Mid-systlic are usually benign if the driver has n signs r symptms f heart disease. Additinal evaluatin is recmmended when murmurs are: Systlic, grade I r II, and the driver has signs r symptms f heart disease. Systlic and grade III r higher. Hlsystlic r late systlic. Diastlic r cntinuus. Exceptins are cmmn with the higher grade murmurs. When in dubt abut the severity f a heart murmur, yu shuld btain additinal evaluatin. Artic Regurgitatin Artic regurgitatin is usually a chrnic cnditin characterized by a prlnged asymptmatic phase and gradual left ventricular (LV) dilatatin. Other cnditins such as infective endcarditis and artic dissectin can result in acute severe artic regurgitatin. The recmmendatins are fr chrnic artic regurgitatin. Recmmendatin parameters fr artic regurgitatin include the severity f the diagnsis, LV size, and the presence f signs r symptms. Mild r mderate artic regurgitatin ccurs in the presence f nrmal LV systlic functin and little r n LV enlargement. Severe artic regurgitatin ccurs with a nrmal LV systlic functin but significant LV dilatatin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Page 105 f 260

Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Mild artic regurgitatin that is asymptmatic. Mderate artic regurgitatin with nrmal LV functin, n r mild LV enlargement, and the driver is asymptmatic. Recmmend nt t certify if: The driver has: Symptms. Mderate artic regurgitatin with abnrmal LV functin r mre than mild LV enlargement. Mnitring/Testing Echcardigraphy repeated every 2 t 3 years when certified with mild r mderate artic regurgitatin. Fllw- up The driver shuld have an annual medical examinatin. T review the Artic Regurgitatin Recmmendatin Table, see Appendix D f this handbk. Waiting Perid Minimum 3 mnths if pst-artic valve repair NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 6 mnths if nt surgically repaired Maximum certificatin perid 1 year if pst-artic valve repair NOTE: The certificatin interval shuld nt exceed the interval required fr adequate mnitring. Recmmend t certify if: The driver has: N symptms. Nrmal LV functin. Page 106 f 260

LV dilatatin: LV end-diastlic dimensin (LVEDD) less than r equal t 60 mm. LV end-systlic dimensin (LVESD) less than r equal t 50 mm. The driver wh has had surgical repair fr severe artic regurgitatin and meets guidelines fr pst-artic valve repair may be recertified fr 1 year. Recmmend nt t certify if: The driver: Is symptmatic. Is unable t achieve wrklad greater than 6 METS n Bruce prtcl. Has reduced left ventricular ejectin fractin less than 50%. Has LV dilatatin: LVEDD greater than 70 mm. LVESD greater than 55 mm. Mnitring/Testing Echcardigraphy repeated every: 6 t 12 mnths if LVEDD less than 60mm r LVESD less than 50 mm. 4 t 6 mnths if LVEDD equal t 60mm r LVESD equal t 50 mm. NOTE: The certificatin interval fr severe artic regurgitatin that has nt been surgically repaired shuld nt exceed 6 mnths even if the mnitring interval is greater than 6 mnths. Fllw- up The driver with severe artic regurgitatin shuld have a semi-annual medical examinatin. If surgically repaired, the driver may have an annual medical examinatin. T review the Artic Regurgitatin Recmmendatin Table, see Appendix D f this handbk. Artic Stensis The mst cmmn cause f artic stensis in adults is a degenerative prcess assciated with many f the risk factrs underlying athersclersis. Artic stensis may cause a heart murmur. Recmmendatin parameters fr artic stensis include the severity f the diagnsis and the presence f signs r symptms. Waiting Perid Minimum 3 mnths if pst surgery NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Page 107 f 260

Recmmend t certify if: The driver has: Mild artic stensis that is asymptmatic. Mderate artic stensis that is asymptmatic and the driver has n disqualifying findings and/r cnditins. Severe artic stensis that has been surgically repaired and meets all artic valve repair surgical guidelines. Recmmend nt t certify if: The driver has mderate artic stensis with ne r mre f the fllwing: Angina. Heart failure. Atrial fibrillatin. Left ventricular dysfunctin with ejectin fractin less than 50%. Thrmbemblism. The driver has severe artic stensis regardless f symptms r left ventricular functin. Mnitring/Testing Echcardigraphy repeated every: 5 years if mild artic stensis. 1 t 2 years if mderate artic stensis. Fllw- up The driver shuld have an annual medical examinatin. T review the Artic Stensis Recmmendatin Table, see Appendix D f this handbk. Artic Valve Repair Artic valve repair is a technique fr repairing the existing artic valve and usually des nt require anticagulant therapy. Early pst-perative evaluatin is required t assess adequacy f repair and extent f residual artic regurgitatin. Waiting Perid Minimum waiting perid 3 mnths NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Page 108 f 260

Recmmend t certify if: The driver: Meets asymptmatic artic stensis r artic regurgitatin qualificatin requirements. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has thrmbemblic cmplicatins. Mnitring/Testing Tw-dimensinal echcardigraphy with Dppler shuld be perfrmed prir t discharge. Additinal mnitring and testing shuld be based n artic regurgitatin severity. Fllw- up The driver shuld have an annual medical examinatin. T review the Artic Regurgitatin Recmmendatin Table r the Artic Stensis Recmmendatin Table, see Appendix D f this handbk. Mitral Regurgitatin Recmmendatin parameters fr mitral regurgitatin include the severity f the diagnsis and the presence f signs r symptms. The develpment f symptms, especially dyspnea, fatigue, rthpnea, and/r parxysmal ncturnal dyspnea, is a marker f a pr prgnsis, including an inability t perfrm driver tasks and increased risk fr sudden cardiac death. Waiting Perid Minimum 3 mnths if pst-surgical cmmissurtmy NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Mild r mderate mitral regurgitatin if asymptmatic, nrmal left ventricular (LV) size and functin, nrmal pulmnary artery pressure. Severe mitral regurgitatin that is asymptmatic. Surgical mitral valve repair fr mitral regurgitatin, is asymptmatic, and has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Page 109 f 260

Recmmend nt t certify if: The driver has mild, mderate, r severe mitral regurgitatin and has: Symptms. Less than 6 METs n Bruce prtcl. Ruptured chrdae r flail leaflet. Atrial fibrillatin. LV dysfunctin. Thrmbemblism. Pulmnary hypertensin. Mnitring/Testing The driver with: Mderate mitral regurgitatin shuld have an annual echcardigraphy. Severe mitral regurgitatin shuld have an exercise tlerance test and echcardigraphy every 6 t 12 mnths. Fllw-up The driver shuld have an annual medical examinatin. T review the Mitral Regurgitatin Recmmendatin Table, see Appendix D f this handbk. Mitral Stensis Recmmendatins fr mitral stensis are based n valve area size and the presence f signs r symptms. Inquire abut episdes f angina r syncpe, fatigue, and the ability t perfrm tasks that require exertin. Waiting Perid Minimum 4 weeks if pst-percutaneus balln mitral valvtmy Minimum 3 mnths if pst-surgical cmmissurtmy NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Mild mitral stensis that is asymptmatic. Page 110 f 260

Mderate mitral stensis that is asymptmatic. Severe mitral stensis and a clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving fllwing: Recmmend nt t certify if: The driver has severe mitral stensis, until successfully treated. Mnitring/Testing The frequency f cardivascular specialist evaluatin depends n the develpment and severity f symptms; hwever, it shuld be perfrmed at least annually, including: Chest X-ray. Electrcardigram. Tw-dimensinal echcardigraphy with Dppler r ther mitral stensis severity assessment. Fllw- up The driver shuld have an annual medical examinatin. T review the Mitral Stensis Recmmendatin Table, see Appendix D f this handbk. Mitral Stensis Treatment Management f mitral stensis is based primarily n the develpment f symptms and pulmnary hypertensin rather than the severity f the stensis itself. Treatment ptins fr mitral stensis include enlarging the mitral valve r cutting the band f mitral fibers. Prcedures include: Percutaneus balln mitral valvtmy. Surgical cmmissurtmy. Symptmatic imprvement ccurs almst immediately, but after 9 years, recurrent symptms are present in apprximately 60% f individuals. Waiting Perid Minimum 4 weeks NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Page 111 f 260

Recmmend t certify if: The driver: Is asymptmatic. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Has experienced n thrmbemblic cmplicatins. Has experienced n pulmnary hypertensin. Meets the certificatin recmmendatins fr the underlying cnditin. Recmmend nt t certify if: The driver has: Thrmbemblic cmplicatins. Pulmnary hypertensin (pulmnary pressure greater than 50% f systemic bld pressure). Mnitring/Testing The driver shuld have an annual cardilgy evaluatin which shuld include: Histry. Physical examinatin. Electrcardigram. Chest X-ray. Tw-dimensinal echcardigraphy with Dppler perfrmed after the prcedure and prir t discharge. The frequency f repeat ech-dppler examinatins is variable and depends upn the initial periprcedural utcme and the ccurrence f symptms. Fllw- up The driver shuld have an annual medical examinatin. T review the Mitral Stensis Recmmendatin Table, see Appendix D f this handbk. Waiting Perid Minimum 3 mnths NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Page 112 f 260

Recmmend t certify if: The driver: Is asymptmatic. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Has experienced n thrmbemblic cmplicatins. Has experienced n pulmnary hypertensin. Meets the certificatin recmmendatins fr the underlying cnditin. Recmmend nt t certify if: The driver has: Thrmbemblic cmplicatins. Pulmnary hypertensin (pulmnary pressure greater than 50% f systemic bld pressure). Mnitring/Testing The driver shuld have an annual cardilgy evaluatin which shuld include: Histry. Physical examinatin. Electrcardigram. Chest X-ray. Tw-dimensinal echcardigraphy with Dppler perfrmed after the prcedure and prir t discharge. The frequency f repeat ech-dppler examinatins is variable and depends upn the initial periprcedural utcme and the ccurrence f symptms. Fllw- up The driver shuld have an annual medical examinatin. T review the Mitral Stensis Recmmendatin Table, see Appendix D f this handbk. Mitral Valve Prlapse The natural histry f mitral valve prlapse is extremely variable and depends n the extent f myxmatus degeneratin, the degree f mitral regurgitatin, and assciatin with ther cnditins. Mitral valve prlapse is usually a benign cnditin. In sme cases, mitral regurgitatin may be prgressive, resulting in left ventricular (LV) and left atrial enlargement, atrial fibrillatin, and cngestive heart failure. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Page 113 f 260

Decisin Maximum certificatin perid 1 year Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Symptms r reduced effrt tlerance due t mitral valve prlapse r mitral regurgitatin. Ruptured chrdae r flail leaflet. Systemic embli. Atrial fibrillatin. Syncpe r dcumented ventricular tachycardia. Severe mitral regurgitatin r LV dysfunctin. Mnitring/Testing Exercise tlerance testing may be helpful t assess symptms. Drivers wh have definite mitral regurgitatin (even if mild) r markedly thickened leaflets, shuld have: Echcardigraphy at least annually. Clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Fllw- up The driver shuld have an annual medical examinatin. Mitral Valve Repair fr Mitral Regurgitatin The majrity f inadequate valvular repair prcedures can be detected in the early periperative perid. Careful evaluatin at this time includes a tw-dimensinal echcardigraphy with Dppler and, if necessary, transesphageal echcardigraphy. Waiting Perid Minimum 3 mnths NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Page 114 f 260

Recmmend t certify if: The driver is asymptmatic and meets the underlying mild, mderate, r severe mitral regurgitatin recmmendatins. The driver shuld als have clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Thrmbemblic cmplicatins. Atrial fibrillatin. Pulmnary hypertensin. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. T review the Mitral Regurgitatin Recmmendatin Table, see Appendix D f this handbk. Prsthetic Valves Prsthetic valves can be mechanical r bilgical. There are a wide range f reprted cmplicatins depending upn the variable methds f reprting, the make and mdel f the prsthesis, the site f implantatin, cmrbidities, and underlying left ventricular (LV) functin, amng ther causes. The clinical curse is heavily influenced by factrs ther than valve-related cmplicatins, fr example, LV dysfunctin, cngestive heart failure, prgressin f disease in ther valves, crnary disease, r pulmnary hypertensin. Waiting Perid Minimum 3 mnths NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver: Is asymptmatic. Has clearance frm a cardivascular specialist wh understands the functins and demands f cmmercial driving. Page 115 f 260

Recmmend nt t certify if: The driver has: Persistent symptms. LV dysfunctin (ejectin fractin less than 40%). Thrmbemblic cmplicatins pst prcedure. Atrial fibrillatin. Pulmnary hypertensin. Inadequate anticagulatin based n Internatinal Nrmalized Rati (INR) checks at least mnthly. Mnitring/Testing If treatment includes anticagulant therapy, the driver shuld meet INR mnitring guidelines. Echcardigraphy is indicated in the event f cncerns abut prsthetic valve dysfunctin, perivalvular leaks, new murmurs, r LV functin. Exercise tlerance testing may be required t assess wrk capacity. Fllw- up The driver shuld have an annual medical examinatin. T review the Valve Replacement Recmmendatin Table, see Appendix D f this handbk. Pulmnary Valve Stensis Pulmnary valve stensis is usually a well-tlerated cardiac lesin nrmally exhibiting a gradual prgressin. Gradual r sudden incapacitatin may, hwever, ccur in certain circumstances. Waiting Perid Minimum 1 mnth if pst-balln valvulplasty Minimum 3 mnths if pst-surgical valvtmy NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Recmmend t certify if: The driver has: Mild r mderate pulmnary valve stensis. Pulmnary valve stensis crrected by surgical valvtmy r balln valvulplasty. Page 116 f 260

Recmmend nt t certify if: The driver has: Symptms f dyspnea, palpitatins, r syncpe. Pulmnary valve peak gradient greater than 50 mm Hg in the presence f a nrmal cardiac utput. Right ventricular pressure greater than 50% systemic pressure. Mre than mild right ventricular hypertrphy nted by echcardigraphy. Mre than mild right ventricular dysfunctin nted by echcardigraphy. Mre than mderate pulmnary valve regurgitatin nted by echcardigraphy. Main pulmnary artery diameter mre than 5 cm nted by echcardigraphy r ther imaging mdality. Mnitring/Testing The driver shuld have annual cardilgy evaluatins by a cardivascular specialist wh is knwledgeable in adult cngenital heart disease and wh understands the functins and demands f cmmercial driving. Fllw- up The driver shuld have an annual medical examinatin. T review the Cngenital Heart Disease Recmmendatin Table, see Appendix D f this handbk. Respiratry (b)(5) 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 a prescriptin, may cause cgnitive difficulties, cmpund the risk fr excessive daytime sleepiness (EDS), r cause ther frms f incapacitatin. Page 117 f 260

Respiratr Regulatin 4 CF 391.41(b)(5) "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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a medical fitness fr duty" examinatin. As the medical examiner, yur fundamental bligatin during the respiratry assessment is t establish whether a driver has a respiratry disease r disrder 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 medical examiner. Yur 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. Key Pints fr Respiratry Examinatin During the physical examinatin, yu shuld ask the same questins as yu wuld fr any individual wh is being assessed fr respiratry diseases r disrders. The FMCSA Medical Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins abut symptms f respiratry disease shuld be asked t supplement infrmatin requested n the frm. Regulatins Yu must review and discuss with the driver any "yes" answers Des the driver have: Shrtness f breath? Lung disease? Emphysema? Asthma? Chrnic brnchitis? Sleep disrder? Pauses in breathing while asleep? Daytime sleepiness? Lud snring? Page 118 f 260

Recmmendatins Questins that yu may ask include 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 while resting r exercising? Wheeze during the day r night? Use respiratry agents? Use xygen therapy? Self-reprt sleepiness that may indicate increased risk fr EDS? Regulatins Yu must evaluate On examinatin, des the driver have: Impaired respiratry functin? Cyansis? Abnrmal: Chest wall expansin? Respiratry rate? Breath sunds, including wheezes r alvelar rales? Findings that may require further testing such as pulmnary tests and/r X-ray f chest? 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, pulmnary rales. 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. NOTE: 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 Page 119 f 260

fund in the Medical Examinatin Reprt frm and a cpy f the applicable medical standard and guidelines with the request. Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative respiratry histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal respiratry tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr. Overall requirements fr cmmercial drivers as well as the specific requirements in the jb descriptin f the driver shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Antihistamine Therapy Bth prescriptin and ver-the-cunter antihistamines are used t treat respiratry tract cngestin. First generatin antihistamines have sedating side effects that may ccur withut the driver being aware. Many first generatin antihistamines are available withut prescriptin. Secnd generatin antihistamines have less incidence f sedating side effects and mst d nt interfere with driving. Sme are available withut prescriptin. NOTE: Yu shuld discuss cmmn prescriptins and ver-the-cunter medicatins relative t the side effects and the risks assciated with using medicatins while driving. Educate the driver t read warning labels n all medicatins. Waiting Perid Minimum The driver shuld abstain frm medicatin fr 12 hurs prir t perating a vehicle NOTE: The individuals respnsible fr cmmercial driver wrk schedules shuld relieve affected drivers frm duty until prper treatment fr the illness has been cmpleted. Page 120 f 260

Decisin Recmmend t certify if: As the medical examiner, yu believe that the treatment des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: Treatment interferes with driving ability. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Allergies and Asthma- related Diseases Allergic Rhinitis Allergic rhinitis, which invlves inflammatin f the nasal prtin f the upper respiratry tract, shuld rarely render the driver medically unqualified fr cmmercial driving. The symptms shuld be treated with nnsedating antihistamines r with lcal sterid sprays that d nt interfere with driving ability. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has cmplicatins and/r treatment that impairs functin, including: Severe cnjunctivitis affecting visin. Inability t keep eyes pen. Phtphbia. Uncntrllable sneezing fits. Sinusitis with severe headaches. Medicatins that cause sedatin r ther side effects that interfere with safe driving. Page 121 f 260

Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- Up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Allergy- related Life- threatening Cnditins These cnditins encmpass systemic anaphylaxis and acute upper airway bstructin induced by allergens, genetic deficiencies, r unknwn mechanisms, including: Stinging insect allergy that may result in acute anaphylaxis fllwing a sting. Preventive measures include carrying an epinephrine injectin device in the truck cab and evaluating the driver fr immuntherapy. Hereditary r acquired angiedema due t deficiency f a serum prtein cntrlling cmplement functin that may result in an acute, life-threatening airway bstructin r severe abdminal pain requiring urgent medical attentin. Preventin and cntrl can and shuld be accmplished with apprpriate prphylactic medicatin. Acute recurrent episdes f idipathic anaphylaxis r angiedema that may ccur unpredictably in sme individuals and lead t sudden nset f severe dyspnea, visual disturbance, lss f cnsciusness, r cllapse. Similar episdes ccur due t knwn allergens, including medicatins, which rdinarily can be avided. Waiting Perid Individuals with a histry f an allergy-related life-threatening cnditin must have undertaken successful preventive measures and/r treatment withut adverse effects befre the driver can be cnsidered medically qualified. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin and the preventin and treatment regimen d nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver with a histry f an allergy-related life-threatening cnditin des nt have: Effective treatment regimen. Successful preventive measures. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Page 122 f 260

Fllw- Up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Asthma Asthma is a cmmn disease. Individuals with asthma generally exhibit reversible airway bstructin that can be treated effectively with pharmaceutical agents such as brnchdilatrs and crticsterids; hwever, asthma ranges in severity frm essentially asymptmatic t ptentially fatal. In sme drivers, cmplicatins f asthma and/r side effects f therapy may interfere with safe driving. Yu are respnsible n a case-by-case basis fr ensuring that the driver is medically fit fr duty. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin is stable and des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver exhibits either: Cntinual, uncntrlled, symptmatic asthma. Significant impairment f pulmnary functin (frced expiratry vlume in the first secnd f expiratin (FEV 1 ) less than 65%) and significant hypxemia (partial pressure f arterial xygen (PaO 2 ) less than 65 millimeters f mercury (mm Hg)). Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Hypersensitivity Pneumnitis Hypersensitivity pneumnitis is an immune-mediated granulmatus interstitial pneumnitis that may present as an acute recurrent, subacute, r chrnic illness variusly manifested by dyspnea, cugh, and fever. The cnditin may nt prevent an individual frm qualifying fr cmmercial driving; hwever, the driver with this cnditin requires medical care t alleviate symptms f dyspnea, cugh, and fever. Page 123 f 260

Als, the driver shuld avid expsure t the causative agent (e.g., transprting the agent) because severe respiratry impairment culd ccur with repeated expsure. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Chest X-ray usually reveals interstitial disease. Serum cntains precipitating antibdies t the causative antigen. Fllw- up The driver shuld have at least biennial medical examinatins. Chrnic Obstructive Pulmnary Disease Chrnic bstructive pulmnary disease (COPD) is nt a single disease, but a grup f medical cnditins characterized by chrnic reductin f maximal expiratry flw mst ften caused by: Chrnic brnchitis. Emphysema. Mst drivers with COPD have a cmbinatin f chrnic brnchitis and emphysema. COPD has an insidius nset. The driver may have substantial reductin in lung functin prir t develping dyspnea n exertin. The cardinal symptms are: Chrnic cugh. Sputum prductin. Dyspnea n exertin. As the disease prgresses, these symptms can becme incapacitating. In the majrity f cases, cigarette smking is a primary etilgic factr. Waiting Perid N recmmended time frame Page 124 f 260

Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver is stable and des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Hypxemia at rest. Chrnic respiratry failure. Histry f cntinuing cugh with cugh syncpe. Mnitring/Testing Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary functin tests. If the frced expiratry vlume in the first secnd f expiratin (FEV1) is less than 65% f that predicted, arterial bld gas measurements shuld be evaluated. NOTE: Smkers have a high incidence f COPD, yet individuals may have a significant reductin in lung functin withut symptms. Spirmetry shuld be perfrmed in all smkers ver the age f 35 years. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Infectius Respiratry Diseases Acute Infectius Diseases Fr illnesses such as the cmmn cld, influenza, and acute brnchitis, the driver shuld: Be relieved frm duty until prper treatment fr the illness has been cmpleted. Abstain frm driving a vehicle fr at least 12 hurs after taking sedating medicatins. Avid perating a vehicle during the time that the disease is cntagius. Many f these cnditins are f shrt duratin and prper treatment fr the illness must be cmpleted fr return-t-wrk. Waiting Perid N recmmended time frame Decisin Maximum certificatin 2 years Page 125 f 260

Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Medicatins used t treat respiratry tract cngestin, such as prescriptins and/r ver-the-cunter antihistamines r narctic antitussives, can cause drwsiness and lss f attentin. Yu shuld educate the driver t refrain frm perating a vehicle fr at least 12 hurs after taking a medicatin with sedating side effects. Fllw- Up The driver shuld have at least biennial medical examinatins. Atypical Tuberculsis Atypical tuberculsis (TB) cvers the same brad spectrum f symptms and disability as TB. Many individuals are clnized, but nt infected with atypical rganisms, usually Mycbacterium avium and Mycbacterium intracellulare. The brad grup f atypical Mycbacteria are cnsidered nninfectius and d nt pse the prblem f cntagin. The majr issue t be determined is the amunt f disease the patient has and the extent f the symptms. Many cases f Mycbacteria cause very few symptms. The X-ray findings are ften migratry and are assciated with cugh, mild hemptysis, and sputum prductin. Atypical TB is nt generally treated with medicatin; hwever, if the driver is using medicatin, yu shuld assess fr side effects that interfere with driving ability. The certificatin issues include the amunt f disease the driver has experienced and the severity f the symptms. The ptential risk is that if the disease is prgressive, respiratry insufficiency may develp. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: The disease remains relatively stable and the driver has nrmal lung functin and tlerates the medical regimen. Page 126 f 260

Recmmend nt t certify if: The driver has: Extensive pulmnary dysfunctin. Weakness. Fatigue. Adverse reactin t medical treatment. Mnitring/Testing Yu shuld perfrm pulmnary functin tests if yu suspect the disease has becme prgressive and may cause extensive pulmnary symptms. Fllw- Up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Pulmnary Tuberculsis Althugh mdem therapy has been extremely successful in cntrlling this disease, pulmnary tuberculsis (TB) persists in sme individuals while n therapy r in individuals wh are nncmpliant with therapy. Advanced TB may cause respiratry insufficiency; hwever, risk f recurrence after adequate therapy is lw. Waiting Perid N recmmended time frame Yu shuld nt certify until: Driver is determined nt t be cntagius. Etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: The driver: Is nt cntagius. Has cmpleted streptmycin therapy withut affecting hearing and/r balance. Is cmpliant with antitubercular therapy. Has n side effects that interfere with safe driving. Page 127 f 260

Recmmend nt t certify if: The driver has: Advanced TB with respiratry insufficiency nt meeting pulmnary functin test criteria. Chrnic TB. Exhibited nncmpliance with antitubercular therapy. Nt cmpleted streptmycin therapy. Residual eighth cranial nerve damage that affects balance and/r hearing t an extent that interferes with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. A psitive intermediate tuberculin skin test (5 tuberculin units (TU)) indicates a previus TB infectin. A psitive purified prtein derivative (PPD) skin test assciated with a nrmal chest X-ray requires n further actin. If X-ray changes are present suggesting pulmnary TB findings, there is a need fr further evaluatin. If the cnversin ccurred within the last year, active disease may develp and prphylactic therapy shuld take place. This circumstance wuld nt require limiting the activities f the driver unless medicatin side effects and/r adverse reactins ccur. Fllw- Up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Nn- infectius Respiratry Diseases This categry includes a number f diseases that cause significant lng-term structural changes in the lungs and/r thrax and, therefre, interfere with the functining f the lungs. Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary testing. Certificatin is determined by clinical evaluatin. Chest Wall Defrmities Acute r chrnic chest wall defrmities may affect the mechanics f breathing with an abnrmal vital capacity as the predminant abnrmality. Examples f these disrders include kyphsis, kyphsclisis, pectus excavatum, ankylsing spndylitis, massive besity, and recent thracic/upper abdminal surgery r injury. The driver certified with a chest wall defrmity shuld have airway functin near nrmal. N specific medicatin exists fr treatment f this categry. Hwever, individuals may be particularly sensitive t the side effects f alchl, antidepressants, and sleeping medicatins, even in small dses. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and any assciated treatment has been shwn t be adequate/effective, safe, and stable. Page 128 f 260

Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Hypxemia at rest. Chrnic respiratry failure. Histry f cntinuing cugh with cugh syncpe. Mnitring/Testing Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary functin tests. If the frced expiratry vlume in the first secnd f expiratin (FEV1) is less than 65% f that predicted, arterial bld gas measurements shuld be evaluated. Fllw- Up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Chrnic Obstructive Pulmnary Disease Chrnic bstructive pulmnary disease (COPD) is nt a single disease, but a grup f medical cnditins characterized by chrnic reductin f maximal expiratry flw mst ften caused by: Chrnic brnchitis. Emphysema. Mst drivers with COPD have a cmbinatin f chrnic brnchitis and emphysema. COPD has an insidius nset. The driver may have substantial reductin in lung functin prir t develping dyspnea n exertin. The cardinal symptms are: Chrnic cugh. Sputum prductin. Dyspnea n exertin. As the disease prgresses, these symptms can becme incapacitating. In the majrity f cases, cigarette smking is a primary etilgic factr. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Page 129 f 260

Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver is stable and des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Hypxemia at rest. Chrnic respiratry failure. Histry f cntinuing cugh with cugh syncpe. Mnitring/Testing Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary functin tests. If the frced expiratry vlume in the first secnd f expiratin (FEV1) is less than 65% f that predicted, arterial bld gas measurements shuld be evaluated. NOTE: Smkers have a high incidence f COPD, yet individuals may have a significant reductin in lung functin withut symptms. Spirmetry shuld be perfrmed in all smkers ver the age f 35 years. Fllw- Up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Cystic Fibrsis Until recently, few individuals with cystic fibrsis (CF) lived int adulthd, but with mdern therapy the number f survivrs cntinues t increase. Treatment fr CF may require almst cntinuus antibitic therapy and daily respiratry therapy t mbilize abnrmal secretins. Chrnic debilitating illness may result in limited physical strength. Sme individuals have a mild frm f the disease that may nt be diagnsed until early adulthd. Individuals must be evaluated as t the extent f their disease and symptms and ability t btain therapy while wrking. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until it has been dcumented that treatment has been shwn t be adequate/effective, safe, and stable and the driver cmplies with cntinuing medical surveillance by the apprpriate specialist. Decisin Maximum certificatin 2 years Page 130 f 260

NOTE: When the driver has a cnditin r treatment that yu believe requires frequent mnitring, the Agency believes that in the absence f ther defined parameters, the general recmmendatin frm the 1988 neurlgical cnference reprt stating, "Any driver with a deficit that requires special evaluatin and screening shuld have annual recertificatin," is a reasnable guideline fr maximum certificatin nt t exceed 1 year. Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Hypxemia at rest. Chrnic respiratry failure. Histry f cntinuing cugh with cugh syncpe. Nt met spirmetry parameters. Unstable cnditin and/r treatment regimen. Mnitring/Testing Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary functin tests. If the frced expiratry vlume in the first secnd f expiratin (FEV1) is less than 65% f that predicted, arterial bld gas measurements shuld be evaluated. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating specialist, but at least annually. Interstitial Lung Disease The interstitial lung diseases (ILDs) are a hetergeneus grup f diseases classified tgether because f cmmn clinical X-ray, physilgic, and pathlgic features. Occupatinal and envirnmental expsures are cmmn causes f ILDs. A histry f breathlessness while driving, walking shrt distances, climbing stairs, handling carg r equipment, and entering r exiting the cab r carg space shuld initiate a careful evaluatin f pulmnary functin fr any disqualifying secndary cnditins. Althugh the curse f ILDs is variable, prgressin f the disease is cmmn and ften insidius. Treatment side effects pse a significant ptential prblem because f the use f cnicsterids and cyttxic agents and shuld be taken int accunt when assessing cmmercial drivers. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Page 131 f 260

Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Hypxemia at rest. Chrnic respiratry failure. Histry f cntinuing cugh with cugh syncpe. Mnitring/Testing Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary functin tests. If the frced expiratry vlume in the first secnd f expiratin (FEV1) is less than 65% f that predicted, arterial bld gas measurements shuld be evaluated. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Pneumthrax Pneumthrax (air in the pleural space) may fllw trauma t the chest r may ccur spntaneusly. Traumatic Pneumthrax - A medical histry and physical examinatin will prvide the details f the event but may nt help t ascertain recvery. Cmplete recvery shuld be cnfirmed by chest X-rays. Spntaneus Pneumthrax - If spntaneus pneumthrax cmplicates an existing lung disease (e.g., emphysema), then the underlying lung disease will determine the chance f a recurrent pneumthrax and the certificatin utcme. Chest X-rays (especially views in deep inspiratin and full expiratin) will cnfirm the reslutin f air frm the pleural space but may shw sme residual pleural scarring r apical blebs r bullae. Waiting Perid N recmmended time frame Ensure cmplete recvery using chest X-rays. If there is air in the pleural space and/r air in the mediastinum (pneummediastinum) additinal time away frm wrk is indicated. Decisin Maximum certificatin 2 years Page 132 f 260

Recmmend t certify if: The driver: Is asymptmatic withut chest pain r shrtness f breath. Has n disqualifying underlying lung disease. Has cnfirmed reslutin f the single spntaneus pneumthrax. Has successful pleurdesis and meets acceptable pulmnary parameters. Recmmend nt t certify if: The driver has: Nt met certificatin parameters. A histry f tw r mre spntaneus pneumthraces n ne side if n successful surgical prcedure has been dne t prevent recurrence. Hypxemia at rest. Chrnic respiratry failure. A histry f cntinuing cugh with cugh syncpe. Mnitring/Testing Chest X-rays with the frequency determined by bth clinical assessment and by recurrence rates. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Pulmnary Functin Tests Physilgical impairment is ptentially present in many lung disrders. Indicatrs fr btaining pulmnary functin testing (PFT) include: Histry f any specific lung disease. Symptms f shrtness f breath, cugh, chest tightness, r wheezing. Cigarette smking in drivers 35 years f age r lder. Spirmetry Yu shuld btain frced expiratry vlume in the first secnd f expiratin (FEV1), frced vital capacity (FVC), and FEV1/FVC rati when any f the fllwing indicatrs are present: Histry f any specific lung disease. Symptms f shrtness f breath, cugh, chest tightness, r wheezing. Cigarette smking in drivers 35 years f age r lder. N further testing is necessary if the lung functin is nrmal and n ther abnrmality is suspected. Abnrmal lung functin shuld be further evaluated. Page 133 f 260

Screening pulse ximetry and/r arterial bld gas (ABG) analysis are indicated when: Cnditin causes airway bstructin and pulmnary functin test results are: FEV 1 less than 65% f the predicted value. FEV 1 /FVC rati less than 65%. Restrictive impairment is present and FVC is less than 60%. Screening Pulse Oximetry If ximetry is less than 92% (ximetry equals 70), the driver must have an ABG analysis. Arterial Bld Gas Analysis Recmmend nt t certify the driver when ABG measurements reveal: Partial pressure f arterial xygen (PaO 2 ) less than: 65 millimeters f mercury (mm Hg) at altitudes belw 5,000 feet. 60 mm Hg at altitudes abve 5,000 feet. Partial pressure f arterial carbn dixide (PaCO 2 ) greater than 45 mm Hg at any altitude. Secndary Respiratry Cnditins and Underlying Disrders Cr Pulmnale Cr pulmnale refers t enlargement f the right ventricle secndary t disrders affecting lung structure r functin. In Nrth America, the mst cmmn pulmnary cause f cr pulmnale is hypxic pulmnary vascnstrictin in individuals with chrnic bstructive pulmnary disease. The mst cmmn cause f right ventricular dilatin r enlargement is pulmnary hypertensin secndary t left heart disease. The majr risks are: Dizziness. Hyptensin. Syncpe. Cmmn side effects f vasdilatrs that may interfere with driving. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until diagnsis is cnfirmed and/r treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years NOTE: When the driver has a cnditin r treatment that yu believe requires frequent mnitring, the Agency believes that in the absence f ther defined parameters, the general recmmendatin frm the 1988 neurlgical cnference reprt stating, "Any driver with a deficit that requires special evaluatin and screening shuld have annual recertificatin," is a reasnable guideline fr maximum certificatin nt t exceed 1 year. Page 134 f 260

Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Dyspnea at rest. Dizziness. Hyptensin. Partial pressure f arterial xygen (PaO 2 ) in arterial bld greater than 65 millimeters f mercury (mm Hg). Mnitring/Testing Obvius difficulty breathing in a resting psitin is an indicatr fr additinal pulmnary functin tests. If the frced expiratry vlume in the first secnd f expiratin (FEV1) is less than 65% f that predicted, arterial bld gas measurements shuld be evaluated. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Pulmnary Hypertensin Pulmnary hypertensin can ccur with r withut cr pulmnale. Significant pulmnary hypertensin is pulmnary artery pressure greater than 50% systemic systlic bld pressure frm any cause. An increased risk fr incapacitatin and sudden death is assciated with: Primary pulmnary hypertensin. Secndary pulmnary hypertensin (e.g., Eisenmenger s syndrme). Waiting Perid N recmmended time frame Yu shuld nt certify the driver until diagnsis is cnfirmed and/r treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin des nt endanger the health and safety f the driver and the public. Page 135 f 260

Recmmend nt t certify if: The driver has: Dyspnea at rest. Dizziness. Hyptensin. Partial pressure f arterial xygen (PaO 2 ) less than 65 millimeters f mercury (mm Hg). Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have fllw-up dependent upn the clinical curse f the cnditin and recmmendatin f the treating healthcare prvider. Neurlgical (b)(7)(8)(9) Cmmercial mtr vehicle (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: Physical demands: Sustained vigilance and attentin. Quick reactins. Cmmunicatin skills. Apprpriate behavir. Crdinatin. Risk frm Headaches Mst individuals have experienced the 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. Page 136 f 260

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 fr 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? What is the ptential fr gradual r sudden incapacitatin? Neurlgical Regulatins 4 CFR 391.41(b)(7)(8)(9) 49 CFR 391.41(b)(7) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn 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." 49 CFR 391.41(b)(8) "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." Page 137 f 260

49 CFR 391.41(b)(9) "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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect 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. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a medical fitness fr duty" examinatin. As the medical examiner, yur fundamental bligatin during the neurlgical assessment is t establish whether a driver has a neurlgical disease r disrder 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 medical examiner. Yur 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. Key Pints fr Neurlgical Examinatin During the physical examinatin, yu shuld ask the same questins as yu wuld any individual wh is being assessed fr neurlgical cncerns. The FMCSA Medical Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins abut neurlgical symptms shuld be asked and dcumented t supplement infrmatin requested n the frm. Regulatins Yu must review and discuss with the driver any "yes" answers 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 paralysis? Spinal injury r disease with residual effects? Recmmendatins Questins that yu may ask include Des the driver: Have current limitatins resulting frm any neurmuscular, nervus, rganic, r functinal disrder? Have symptms related t r caused by neurlgical diseases? Page 138 f 260

Use medicatin t treat neurlgical disrders, including: Anticnvulsants (anticnvulsant therapy recmmendatins). Anticagulants (anticagulant therapy recmmendatins). Antiplatelet drugs. Central nervus system stimulants and depressants. Des 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)? Des the driver have signs f undiagnsed neurlgical disease? Cnsider: Is the infrmatin crrect and cmplete? 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 Yu must evaluate On examinatin, des the driver have: Cmprmised equilibrium, crdinatin, and/r speech pattern? Asymmetrical deep tendn reflexes? Abnrmal patellar and Babinski reflexes? Sensry abnrmalities? Psitinal abnrmalities? Ataxia? Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including if available: Onset date and diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Page 139 f 260

Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal neurlgical tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr. Medical fitness fr duty als requires the driver t be free f any neurlgical residual limitatins sufficiently severe t interfere with: Cgnitive abilities. Judgment. Attentin. Cncentratin. Visin. Physical strength. Agility. Reactin time. Overall requirements fr cmmercial drivers, as well as the specific requirements in the jb descriptin f the driver, shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Anticagulant Therapy The mst current guidelines fr the use f warfarin (Cumadin) fr cardivascular diseases are fund in the Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers. Anticagulant therapy may be utilized in the treatment f cardivascular r neurlgical cnditins. The guidelines emphasize that the certificatin decisin shuld be based n the underlying medical disease r disrder requiring medicatin, nt the medicatin itself. Waiting Perid Minimum 1 mnth stabilized NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin perid 1 year Page 140 f 260

Recmmend t certify if: The driver: Is stabilized n medicatin fr at least 1 mnth. Prvides a cpy f the internatinal nrmalized rati (INR) results at the examinatin. Has at least mnthly INR mnitring. Recmmend nt t certify if: INR is nt being mnitred. INR is nt therapeutic. Underlying disease is disqualifying. Mnitring/Testing The driver shuld btain INR mnitring at least mnthly. Fllw- up The driver shuld bring results f INR mnitring t the examinatin. T review the Venus Disease Recmmendatin Tables, see Appendix D f this handbk. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a cerebrvascular disrder. NOTE: The ratinale fr disqualificatin is the high rate f cmplicatins assciated with bleeding that can incapacitate the driver while perating a vehicle. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Anticnvulsant Therapy Anticnvulsant therapy is used t cntrl r prevent seizures. Even with effective therapy there is still a risk fr a seizure shuld the medicatin be missed inadvertently. Page 141 f 260

Anticnvulsants are als prescribed fr ther cnditins that d nt cause seizures, including sme psychiatric disrders (fr antimanic and md-stabilizing effects) and t lessen chrnic pain. Side effects may include: Depressed md. Cgnitive deficits. Decreased reflex respnses. Unsteadiness. Sedatin. Small dses used fr chrnic pain are less likely t be assciated with side effects that can interfere with safe driving than the dses used t treat ther disrders. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the medicatin has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe: Nature and severity f the underlying cnditin des nt interfere with safe driving. Effects f medicatin used while perating a cmmercial mtr vehicle des nt endanger the safety f the driver and the public. Recmmend nt t certify if: The driver uses anticnvulsant medicatins t cntrl r prevent seizures. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have annual medical examinatins. Episdic Neurlgical Cnditins Episdic neurlgical cnditins guidance can be gruped based n the type f risk assciated with the cnditin. The first grup cnsiders the types f headache, vertig, and dizziness that can affect cgnitive abilities, judgment, attentin, and cncentratin, as well as impact sensry r mtr functin sufficiently t interfere with the ability t drive a cmmercial mtr vehicle safely. Page 142 f 260

The secnd grup addresses the cnditins that are knwn t cause r increase the risk fr seizures, including epilepsy. Acute Seizures Structural Insult t the Brain Individuals may have a seizure at the time f a brain insult. In many situatins, the ccurrence f seizures is a reflectin f the site f injury but may als be a surrgate fr severity. Nnetheless, mst neurlgical cnditins in which acme r early seizures may ccur are als risk factrs fr later unprvked seizures. In fact, the ccurrence f early seizures adds a significant increment f risk fr later epilepsy t that assciated with the primary cnditin. In general, the risk fr subsequent unprvked seizures is greatest in the first 2 years fllwing the acute insult. Apprximately 12% f individuals suffering an cclusive cerebrvascular insult resulting in a fixed neurlgical deficit will experience a seizure at the time f the insult. Unprvked seizures will ccur within the next 5 years in 16% f all individuals with an cclusive vascular insult. This rate seems nt t be mdified significantly by the ccurrence f early seizures. The risk is increased primarily in individuals with lesins assciated with cerebral crtical r subcrtical deficits. The same risk f seizure and recmmendatins are applicable fr intracerebral r subarachnid hemrrhage. The length f time an individual is seizure free and ff anticnvulsant medicatin is cnsidered the best predictr f future risk fr seizures. Therefre, accrding t medical guidelines, fr the entire waiting perid befre being cnsidered fr certificatin, the driver shuld be bth: Seizure free. Off anticnvulsant medicatin prescribed fr cntrl f seizures. Fr thse individuals wh survive severe head injury, the risk fr develping unprvked seizures des nt decrease significantly ver time. Based upn the risk fr unprvked seizures alne, the driver shuld nt be cnsidered fr certificatin. NOTE: Surgical prcedures invlving dural penetratin have a risk fr subsequent epilepsy similar t that f severe head trauma. Individuals wh have undergne such prcedures, including thse wh have had surgery fr epilepsy, shuld nt be cnsidered eligible fr certificatin. Waiting Perid Minimum 1 year seizure free and ff anticnvulsant medicatin fllwing: Mild insult withut early seizures. Strke withut risk fr seizures. Intracerebral r subarachnid hemrrhage withut risk fr seizures. Minimum 2 years seizure free and ff anticnvulsant medicatin fllwing: Mderate insult withut early seizures. Mild insult with early seizures. Minimum 5 years seizure free and ff anticnvulsant medicatin fllwing: Mderate insult with early seizures. Strke with risk fr seizures. Intracerebral r subarachnid hemrrhage with risk fr seizures. NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Page 143 f 260

Decisin Maximum certificatin 1 year Recmmend t certify if: The driver with a histry f mild r mderate insult has: Cmpleted the minimum waiting perid seizure free and ff anticnvulsant medicatin. Nrmal physical examinatin, neurlgical examinatin including neur-phthalmlgical evaluatin, and neurpsychlgical test. Clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has a histry f a severe brain insult with r withut early seizures. The driver with a mild r mderate insult: Has nt cmpleted the minimum waiting perid seizure free and ff anticnvulsant medicatin. Des nt have a nrmal physical examinatin, neurlgical examinatin including neurphthalmlgical evaluatin, r neurpsychlgical test. Des nt have clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. Acute Seizures Systemic Metablic Illness Seizures are the nrmal reactin f a prperly functining nervus system t adverse events. In the presence f systemic metablic illness, seizures are generally related t the cnsequences f a general systemic alteratin f bichemical hmestasis and are nt knwn t be assciated with any inherent tendency t have further seizures. The risk fr recurrence f seizures is related t the likelihd f recurrence f the inciting cnditin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Page 144 f 260

Recmmend t certify if: The underlying systemic metablic dysfunctin has been crrected. The driver has n disqualifying risk f recurrence f the primary cnditin. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have at least biennial medical examinatins. Childhd Febrile Seizures Febrile seizures ccur in frm 2% t 5% f the children in the United States befre 5 years f age and seldm ccur after 5 years f age. Frm a practical standpint, mst individuals wh have experienced a febrile seizure in infancy are unaware f the event and the cnditin wuld nt be readily identified thrugh rutine screening. Mst f the increased risk fr unprvked seizure is appreciated in the first 10 years f life. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: The histry f seizures is limited t childhd febrile seizures. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have at least biennial medical examinatins. Page 145 f 260

Epilepsy The advisry criteria fr 49 CFR 391.41(b)(8) says, "Epilepsy is a chrnic functinal disease characterized by seizures r episdes that ccur withut warning, resulting in lss f vluntary cntrl which may lead t lss f cnsciusness and/r seizures. Therefre, the fllwing drivers cannt be qualified: (1) a driver wh has a medical histry f epilepsy; (2) a driver wh has a current clinical diagnsis f epilepsy; r (3) a driver wh is taking antiseizure medicatin." Fllwing an initial unprvked seizure, the cmmercial mtr vehicle (CMV) driver shuld be seizure free and ff anticnvulsant medicatin fr at least 5 years t distinguish between a medical histry f a single instance f seizure and epilepsy. A secnd unprvked seizure, regardless f the elapsed time between seizures, wuld cnstitute a medical histry f epilepsy and the driver wuld n lnger meet the physical requirements fr 49 CFR 391.41(b)(8). NOTE: Epilepsy medical guidelines are currently under review by the Federal Mtr Carrier Safety Administratin. While there have been n changes thrugh the rulemaking prcess t the wrding f 49 CFR 391.41(b)(8), current advisry criteria allw that sme "drivers with a histry f epilepsy/seizures ff antiseizure medicatin and seizure-free fr 10 years may be qualified t drive a CMV in interstate cmmerce." Waiting Perid Minimum 10 years ff anticnvulsant medicatin and seizure free Decisin Recmmend t certify if: The driver has cmpleted a waiting perid f 10 years ff anticnvulsant medicatin and seizure free and yu, as the medical examiner, believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Accrding t regulatin, yu must nt certify if: The driver has: An established medical histry f epilepsy. A clinical diagnsis f epilepsy. Any ther cnditin likely t cause lss f cnsciusness r any lss f ability t cntrl a CMV. NOTE: If yu chse t certify a driver with an established medical histry f epilepsy, be sure t include in yur dcumentatin reference t the advisry criteria and all medical evaluatin supprting yur decisin. Recmmend nt t certify if: The driver is taking anticnvulsant medicatin because f a medical histry f ne r mre seizures r is at risk fr seizures. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Clearance frm a specialist in neurlgical diseases wh understands the Page 146 f 260

functins and demands f cmmercial driving is a prudent curse f actin if chsing t certify the driver with an established histry f epilepsy. Fllw- up The driver shuld have an annual medical examinatin. Headaches Chrnic r chrnic-recurring headache syndrmes can ptentially interact with ther neurlgical diagnstic categries in tw ways: Thrugh cmplicatins (e.g., strke in relatin t migraine). As a result f assciated features f a particular syndrme (e.g., the visual distrtin r disequilibrium assciated with a migraine attack). The fllwing types f headaches may interfere with the ability t drive a cmmercial mtr vehicle safely: Migraines. Tensin-type headaches. Cluster headaches. Pst-traumatic head injury syndrme. Headaches assciated with substances r withdrawal. Cranial neuralgias. Atypical facial pain. Cnsider headache frequency and severity when evaluating a driver whse histry includes headaches. In additin t pain, inquire abut ther symptms caused by headaches, such as visual disturbances, that may interfere with safe driving. Cnsider the treatment used t relieve headaches. D the effects r side effects f treatment interfere with safe driving? Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the health and safety f the driver and the public. Page 147 f 260

Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have at least biennial medical examinatins. Single Unprvked Seizure An unprvked seizure ccurs in the absence f an identifiable acute alteratin f systemic metablic functin r acute insult t the structural integrity f the brain. There may be a knwn r distant cause f the seizure. While individuals wh experience a single unprvked seizure d nt have a diagnsis f epilepsy, they are clearly at a higher risk fr having further seizures. The verall rate ccurrence is estimated t be 36% within the first 5 years fllwing the seizure. After 5 years, the risk fr recurrence is dwn t 2% t 3% per year fr the ttal grup. Fllwing an initial unprvked seizure, the driver shuld be seizure free and ff anticnvulsant medicatin fr at least 5 years t distinguish between a medical histry f a single unprvked seizure and epilepsy (tw r mre unprvked seizures). A secnd unprvked seizure, regardless f the elapsed time between seizures, wuld cnstitute a medical histry f epilepsy, and the driver wuld n lnger meet the physical requirements fr 49 CFR 391.41(b)(8). The length f time an individual is seizure free and ff anticnvulsant medicatin is cnsidered the best predictr f future risk fr seizures. Therefre, fr the entire waiting perid befre being cnsidered fr certificatin, the driver shuld be bth: Seizure free. Off anticnvulsant medicatin prescribed fr cntrl f seizures. Waiting Perid Minimum 5 years seizure free and ff anticnvulsant medicatin NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver has: Cmpleted the minimum waiting perid seizure free and ff anticnvulsant medicatin. Clearance frm a neurlgist wh specializes in epilepsy and understands the functins and demands f cmmercial driving. Page 148 f 260

Recmmend nt t certify if: The driver: Has nt cmpleted the minimum waiting perid seizure free and ff anticnvulsant medicatin. Des nt have clearance frm a neurlgist wh specializes in epilepsy and understands the functins and demands f cmmercial driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have at least biennial medical examinatins. Vertig and Dizziness The nrmal ability t maintain balance and rientatin while perating a cmmercial mtr vehicle (CMV) depends upn peripheral nervus system (PNS) sensry input frm three majr systems and the apprpriate mtr integratin in the central nervus system (CNS). The three PNS sensry systems are vestibular, visual, and prpriceptin. Inapprpriate interactins f these systems r interactins within the CNS may prduce an unsafe degree f vertig r dizziness that endangers the health and safety f the driver and the public. The mst cmmn medicatins used t treat vertig are antihistamines, benzdiazepines, and phenthiazines. Use f either benzdiazepines r phenthiazines fr the treatment f vertig wuld render the driver medically unqualified. Special cnsideratin shuld be given t the pssible sedative side effects f antihistamines. The medical examiner shuld determine if these drugs prduce sedatin in the individual driver. Waiting Perid Minimum 2 mnths asymptmatic with diagnsis f: Benign psitinal vertig. Acute and chrnic peripheral vestibulpathy. NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 2 years NOTE: Any driver with a deficit that requires special evaluatin and screening shuld be recertified annually. Recmmend t certify if: The driver has a diagnsis f: Benign psitinal vertig and has cmpleted the apprpriate symptm-free waiting perid. Page 149 f 260

Acute and chrnic peripheral vestibulpathy and has cmpleted the apprpriate symptm-free waiting perid. A medical cnditin f a nature and severity that des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has a diagnsis f: Benign psitinal vertig and has been symptmatic within the past 2 mnths. Acute and chrnic peripheral vestibulpathy and has been symptmatic within the past 2 mnths. Meniere's disease. Labyrinthine fistula. Nnfunctining labyrinths. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have at least biennial medical examinatins. Infectins f the Central Nervus System The guidelines fr central nervus system (CNS) infectin cnsider diagnsis and whether r nt the driver has a histry f early seizures with the cnditin. Aseptic meningitis is nt assciated with any increase in risk fr subsequent unprvked seizures; therefre, n restrictins shuld be cnsidered fr such individuals, and they shuld be cnsidered qualified t btain a license t perate a cmmercial vehicle. A driver with a current clinical CNS diagnsis r signs and symptms f a CNS infectin shuld nt be cnsidered fr certificatin until the etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Page 150 f 260

Waiting Perid Minimum 1 year seizure free and ff anticnvulsant medicatin fllwing: Bacterial meningitis withut early seizures. Viral encephalitis withut early seizures. Minimum 5 years seizure free and ff anticnvulsant medicatin fllwing: Bacterial meningitis with early seizures. Minimum 10 years seizure free and ff anticnvulsant medicatin fllwing: Viral encephalitis with early seizures. Decisin Maximum certificatin 2 years Recmmend t certify if: The driver has a histry f: Aseptic meningitis. Bacterial meningitis and has cmpleted the apprpriate recmmended waiting perid. Viral encephalitis and has cmpleted the apprpriate recmmended waiting perid. Recmmend nt t certify if: The driver has a current CNS infectin. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up Yu may n a case-by-case basis determine that annual medical examinatin is apprpriate. Neurmuscular Diseases As a grup, neurmuscular diseases are usually insidius in nset and slwly prgressive. The rate f prgressin will vary and is generally measured in mnths t years. Rare neurmuscular diseases may be episdic prducing weakness ver minutes t hurs. Yu must cnsider the effects f neurmuscular cnditins n the physical abilities f the driver t initiate and maintain safe driving including steering, braking, clutching, getting in and ut f vehicles, and reactin time. Examinatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving may be required t assess the status f the disease. As the medical examiner, yu determine certificatin status. Page 151 f 260

Autnmic Neurpathy Autnmic neurpathy affects the nerves that regulate vital functins, including the heart muscle and smth muscles. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As a medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has: Cardivascular autnmic neurpathy that causes: Resting tachycardia. Orthstatic bld pressure. Other rgan autnmic neurpathy that interferes with driving ability. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have a biennial physical examinatin r mre frequently if needed t adequately mnitr medical fitness fr duty. Cnditins Assciated with Abnrmal Muscle Activity This grup f disrders is characterized by abnrmal muscle excitability caused by abnrmalities either in the nerve r in the muscle membrane. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Page 152 f 260

Recmmend t certify if: As a medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the health and safety f the driver and the public. Recmmend nt t certify if: The driver has a diagnsis f: Mytnia. Isaac's syndrme. Stiff-man syndrme. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have a biennial physical examinatin r mre frequently if needed t adequately mnitr medical fitness fr duty. Cngenital Mypathies Cngenital mypathies are a grup f disrders that may be distinguished frm thers because f specific, well-defined structural alteratins f the muscle fiber and may be prgressive r nnprgressive. These disrders include: Central cre disease. Centrnuclear mypathy. Cngenital muscular dystrphy. Rd (nemaline) mypathy. Inflammatry mypathies are acquired muscle diseases that may be treated. These disrders include: Dermatmysitis. Inclusin bdy mysitis. Plymysitis. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f a cngenital mypathy disrder. Page 153 f 260

NOTE: Neurmuscular disrders represent a cmplex grup f cnditins. The severity can vary with the individual and in certain instances may be treatable r nnprgressive. Guidelines fr recnsideratin f the decisin nt t certify include: Evaluatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving. Specialist may recmmend a simulated driving skills test r equivalent functinal test. Annual recertificatin that repeats specialist evaluatin and driving test when indicated. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Metablic Muscle Diseases Metablic muscle diseases are a grup f disrders cmprised f cnditins affecting the energy metablism f muscle r an imbalance in the chemical cmpsitin either within r surrunding the muscle. Cnditins may affect glycgen and glyclytic metablism, lipid metablism, mitchndrial metablism, r ptassium balance f the muscle. Unlike mst ther neurmuscular disrders, these cnditins may either be insidiusly prgressive r episdic. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f a metablic muscle disease. NOTE: Neurmuscular disrders represent a cmplex grup f cnditins. The severity can vary with the individual and in certain instances may be treatable r nnprgressive. Guidelines fr recnsideratin f the decisin nt t certify include: Evaluatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving. Specialist may recmmend a simulated driving skills test r equivalent functinal test. Annual recertificatin that repeats specialist evaluatin and driving test when indicated. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Page 154 f 260

Mtr Neurn Diseases This grup f disrders includes: Hereditary spinal muscular atrphy in bth juvenile and adult frms. Acquired amytrphic lateral sclersis cnditins prducing degeneratin f the mtr nerve cells in the spinal crd. As a grup these are debilitating, insidiusly prgressive cnditins that interfere with the ability t drive cmmercial vehicles. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f a mtr neurn disease. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Muscular Dystrphies Muscular dystrphies are hereditary, prgressive, degenerative diseases f the muscle that interfere with safe driving. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f a muscular dystrphy disease. Page 155 f 260

NOTE: Neurmuscular disrders represent a cmplex grup f cnditins. The severity can vary with the individual and in certain instances may be treatable r nnprgressive. Guidelines fr recnsideratin f the decisin nt t certify include: Evaluatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving. Specialist may recmmend a simulated driving skills test r equivalent functinal test. Annual recertificatin that repeats specialist evaluatin and driving test when indicated. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Neurmuscular Junctin Disrders This grup f disrders includes: Myasthenia gravis. Myasthenic syndrme. In additin t limb muscle weakness, visin is ften affected and easy fatigability is a cmmn manifestatin. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f a neurmuscular junctin disrder. NOTE: Neurmuscular disrders represent a cmplex grup f cnditins. The severity can vary with the individual and in certain instances may be treatable r nnprgressive. Guidelines fr recnsideratin f the decisin nt t certify include: Evaluatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving. Specialist may recmmend a simulated driving skills test r equivalent functinal test. Annual recertificatin that repeats specialist evaluatin and driving test when indicated. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Page 156 f 260

Peripheral Neurpathies This grup f disrders cnsists f hereditary and acquired cnditins where the nerves, including the axn and myelin r the myelin selectively utside the spinal crd, are affected. These cnditins may affect the sensry r mtr nerves individually, r bth may be affected. Peripheral neurpathy may be a cmplicatin f diabetes mellitus. Yu shuld evaluate the sensry mdalities f pain, light tuch, psitin, and vibratry sensatin in the tes, feet, fingers, and hands fr signs f peripheral neurpathy. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f a peripheral neurpathy. NOTE: Neurmuscular disrders represent a cmplex grup f cnditins. The severity can vary with the individual and in certain instances may be treatable r nnprgressive. Guidelines fr recnsideratin f the decisin nt t certify include: Evaluatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving. Specialist may recmmend a simulated driving skills test r equivalent functinal test. Annual recertificatin that repeats specialist evaluatin and driving test when indicated. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Prgressive Neurlgical Cnditins Guidelines recmmend that any driver having neurlgical signs r symptms be referred t a neurlgist fr mre detailed and qualified evaluatin f neurlgical status in relatin t certificatin fr driving a cmmercial mtr vehicle. 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 Medical Examinatin Reprt frm descriptin f the driver rle and a cpy f the applicable medical standards (page 4) and guidelines with the request. Central Nervus System Tumrs The central nervus system (CNS) is the seat f ur intelligence and emtins, and an afflictin f the CNS impacts everyday functining in a direct and visible manner. Brain tumrs may alter cgnitive abilities and judgment, and these symptms may ccur early in the curse f the cnditin. Sensry and Page 157 f 260

mtr abnrmalities may be prduced bth by brain tumrs and by spinal crd tumrs, depending n the lcatin. Fr sme benign tumrs, certificatin may be pssible after successful surgical treatment. The length f time an individual is seizure free and ff f anticnvulsant medicatin is cnsidered the best predictr f future risk fr seizures. Therefre, fr the entire waiting perid befre being cnsidered fr certificatin, the driver must be bth: Seizure free. Off anticnvulsant medicatin prescribed fr cntrl f seizures. Waiting Perid Minimum 1 year pst-surgical remval f: Infratentrial meningimas. Acustic neurmas. Pituitary adenmas. Spinal benign tumrs. Benign extra-axial tumrs. Minimum 2 years pst-surgical remval f: Benign supratentrial tumrs. Spinal tumrs. NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver has: Cmpleted the apprpriate minimum waiting perid. Stable nnprgressive deficit r n neurlgical deficit. Imaging that shws n tumrs. NOTE: If the driver has a histry f seizures, use the apprpriate seizure guidelines. Recmmend nt t certify if: The driver has: Nt cmpleted apprpriate waiting perid. Primary r metastatic malignant tumrs f the nervus system. Benign nervus system tumrs. Page 158 f 260

Mnitring/Testing Since meningimas may be multiple, residual examinatins must shw n evidence f recurrent r new tumrs. Evaluatin shuld be perfrmed by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving. Fllw- up The driver shuld have an annual medical examinatin. Dementia Dementia is a prgressive decline in mental functining that can interfere with memry, language, spatial functins, higher rder perceptual functins, prblem slving, judgment, behavir, and emtinal functins. Alzheimer's and Pick's diseases bth cause dementia and have symptms that are incmpatible with the safe driving. Neither disease has a specific diagnstic test, with mild symptms typically present fr years befre the diagnsis is made. Alzheimer's is the mst cmmn degenerative disease. The ratinale fr making a decisin nt t certify when a diagnsis f dementia is present includes: There are n current data prviding evidence that a driver with diagnsed dementia can drive a cmmercial mtr vehicle safely. The disease rate f prgressin is variable. Waiting Perid Nt applicable. Decisin Recmmend t certify if: Nt applicable. Recmmend nt t certify if: The driver has a diagnsis f dementia. Mnitring/Testing Nt applicable. Fllw- up Nt applicable. Static Neurlgical Cnditins Static neurlgical cnditins include cmmn cerebrvascular disease, as well as head and spinal crd injuries. Cerebrvascular events may cause cgnitive, judgment, attentin, cncentratin, and/r mtr and sensry impairments that can interfere with nrmal peratin f a cmmercial mtr vehicle (CMV). Drivers with several types f cerebrvascular disease are als at risk fr recurring events that can happen withut warning. Drivers with ischemic cerebrvascular disease are als at high risk fr acute cardiac events, including mycardial infarctin r sudden cardiac death. Recurrent cerebrvascular symptms r cardiac events can ccur with sufficient frequency t cause cncern abut the safe peratin f a CMV. Page 159 f 260

The cmmn types f cerebrvascular disease are: Transient ischemic attack/minr strke with minimal r n residual impairment. Emblic r thrmbtic cerebral infarctin with mderate t majr residual impairment. Intracerebral r subarachnid hemrrhage. Head injury recmmendatins include cmplete physical examinatin, neurlgical examinatin, and neurpsychlgical testing with nrmal results and the use f the seizure guidelines t determine certificatin status. Spinal crd injury resulting in paraplegia is disqualifying. Any weakness shuld be evaluated t determine whether the deficit interferes with the jb requirements f a cmmercial driver. Any driver with a neurlgical deficit that requires special evaluatin and screening shuld have annual medical examinatins. Emblic and Thrmbtic Strkes Mre than 3 millin individuals have survived a strke, and it is a majr cause f lng-term disability. Emblic and thrmbtic cerebral infarctins are the mst cmmn frms f cardivascular disease. Risk fr cmplicating seizures is assciated with the lcatin f the lesins. Cerebellum and brainstem vascular lesins are nt assciated with an increased risk fr seizures. Crtical and subcrtical deficits are assciated with an increased risk fr seizures. Evaluatin by a neurlgist is necessary t cnfirm the area f invlvement. Drivers with emblic r thrmbtic cerebral infarctins will have residual intellectual r physical impairments. Fatigue, prlnged wrk, and stress may exaggerate the neurlgical residuals frm a strke. Mst recvery frm a strke will ccur within 1 year f the event. The neurlgical examinatin shuld include assessment f: Cgnitive abilities. Judgment. Attentin. Cncentratin. Visin. Physical strength and agility. Reactin time. Waiting Perid Minimum 1 year if nt at risk fr seizures (cerebellum r brainstem vascular lesins) Minimum 5 years if at risk fr seizures (crtical r subcrtical deficits) NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Page 160 f 260

Recmmend t certify if: The driver with a histry f strke has: Cmpleted the apprpriate waiting perid. Nrmal physical examinatin, neurlgical examinatin including neur-phthalmlgical evaluatin, and neurpsychlgical testing. N neurlgical residuals r, if present, residuals f a severity that des nt interfere with ability t perate a cmmercial mtr vehicle. Clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver: Has nt cmpleted the apprpriate waiting perid. Uses ral anticagulant therapy because f the risks assciated with excessive bleeding. Uses any ther drug r cmbinatin f drugs that have ptentially high rates f cmplicatins (e.g., depressing effects n the nervus system). Has residual intellectual r physical impairments that interfere with cmmercial driving. Des nt have clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. Intracerebral and Subarachnid Hemrrhages Intracerebral hemrrhage results frm bleeding int the substance f the brain and subarachnid hemrrhage reflects bleeding primarily int the spaces arund the brain. Bleeding ccurs as a result f a number f cnditins including hypertensin, hemrrhagic disrders, trauma, cerebral aneurysms, neplasms, arterivenus malfrmatins, and degenerative r inflammatry vasculpathies. Subarachnid and intracerebral hemrrhages can cause serius residual neurlgical deficits in: Cgnitive abilities. Judgment. Attentin. Physical skills. The risk fr seizures fllwing intracerebral and subarachnid hemrrhages is assciated with the lcatin f the hemrrhage: Cerebellum and brainstem vascular hemrrhages are nt assciated with an increased risk fr seizures. Page 161 f 260

Crtical and subcrtical hemrrhages are assciated with an increased risk fr seizures. Apprpriate evaluatin by a neurlgist is required t cnfirm the area f invlvement. The recmmendatins fr intracranial and subarachnid hemrrhages parallel recmmendatins fr strkes. Waiting Perid Minimum 1 year if nt at risk fr seizures (cerebellum r brainstem vascular lesins) Minimum 5 years if at risk fr seizures (crtical r subcrtical deficits) NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver with a histry f intracranial r subarachnid hemrrhage has: Cmpleted the apprpriate waiting perid. Nrmal physical examinatin, neurlgical examinatin including neur-phthalmlgical evaluatin, and neurpsychlgical testing. N neurlgical residuals r, if present, residuals f a severity that d nt interfere with the ability t perate a cmmercial mtr vehicle. Clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver: Has nt cmpleted the apprpriate waiting perid Uses ral anticagulant therapy because f the risks assciated with excessive bleeding. Uses any ther drug r drug cmbinatin with a ptentially high rate f cmplicatins (e.g., depressing effects n the nervus system). Has residual intellectual r physical impairments that interfere with cmmercial driving. Des nt have clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. Page 162 f 260

Transient Ischemic Attack Intracerebral hemrrhage results frm bleeding int the substance f the brain and subarachnid hemrrhage reflects bleeding primarily int the spaces arund the brain. Bleeding ccurs as a result f a number f cnditins including hypertensin, hemrrhagic disrders, trauma, cerebral aneurysms, neplasms, arterivenus malfrmatins, and degenerative r inflammatry vasculpathies. Subarachnid and intracerebral hemrrhages can cause serius residual neurlgical deficits in: Cgnitive abilities. Judgment. Attentin. Physical skills. The risk fr seizures fllwing intracerebral and subarachnid hemrrhages is assciated with the lcatin f the hemrrhage: Cerebellum and brainstem vascular hemrrhages are nt assciated with an increased risk fr seizures. Crtical and subcrtical hemrrhages are assciated with an increased risk fr seizures. Apprpriate evaluatin by a neurlgist is required t cnfirm the area f invlvement. The recmmendatins fr intracranial and subarachnid hemrrhages parallel recmmendatins fr strkes. Waiting Perid Minimum 1 year if nt at risk fr seizures (cerebellum r brainstem vascular lesins) Minimum 5 years if at risk fr seizures (crtical r subcrtical deficits) NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver with a histry f intracranial r subarachnid hemrrhage has: Cmpleted the apprpriate waiting perid. Nrmal physical examinatin, neurlgical examinatin including neur-phthalmlgical evaluatin, and neurpsychlgical testing. N neurlgical residuals r, if present, residuals f a severity that d nt interfere with the ability t perate a cmmercial mtr vehicle. Clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Page 163 f 260

Recmmend nt t certify if: The driver: Has nt cmpleted the apprpriate waiting perid Uses ral anticagulant therapy because f the risks assciated with excessive bleeding. Uses any ther drug r drug cmbinatin with a ptentially high rate f cmplicatins (e.g., depressing effects n the nervus system). Has residual intellectual r physical impairments that interfere with cmmercial driving. Des nt have clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. Traumatic Brain Injury Traumatic brain injury (TBI) is an insult t the brain caused by an external physical frce, which may prduce a diminished r altered state f cnsciusness, including cma, resulting in lng-term impairment f cgnitive r physical functin. Disturbances f behaviral r emtinal functining may result in ttal r partial disability and/r psychlgical maladjustment. Many peple with TBI suffer lss f memry and reasning ability, experience speech and/r language prblems, and exhibit emtinal and behaviral changes that are medically disqualifying fr cmmercial driving. TBI is classified by depth f dural penetratin and duratin f lss f cnsciusness. The three classes are: Severe head injury penetrates the dura and causes a lss f cnsciusness lasting lnger than 24 hurs. There is a high risk fr unprvked seizures, and the risk des nt diminish ver time. Mderate head injury des nt penetrate the dura but causes a lss f cnsciusness lasting lnger than 30 minutes, but less than 24 hurs. Mild head injury has n dural penetratin r lss f cnsciusness and lasts fr fewer than 30 minutes. Be sure t distinguish between mild TBI with r withut early seizures. The length f time an individual is seizure free and ff anticnvulsant medicatin is cnsidered the best predictr f future risk fr seizures. Therefre, fr the entire waiting perid befre being cnsidered fr certificatin, the driver must be bth: Seizure free. Off anticnvulsant medicatin prescribed fr cntrl f seizure. NOTE: Surgical prcedures invlving dural penetratin have a risk fr subsequent epilepsy similar t that f severe head trauma. Individuals wh have undergne such prcedures, including thse wh have had surgery fr epilepsy, shuld nt be cnsidered eligible fr certificatin. Page 164 f 260

Waiting Perid Minimum 2 years seizure free and ff anticnvulsant medicatin fllwing: Mderate TBI withut early seizures. Mild TBI with early seizures. Minimum 5 years seizure free and ff anticnvulsant medicatin fllwing: Mderate TBI with early seizures. NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Maximum certificatin 2 years fr mild TBI withut early seizures Recmmend t certify if: The driver with a mild r mderate TBI wh has: Cmpleted the minimum waiting perid seizure free and ff anticnvulsant medicatin. Nrmal physical examinatin, neurlgical examinatin including neur-phthalmlgical evaluatin, and neurpsychlgical test. Clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has sustained a severe TBI with r withut early seizures. The driver with a mild r mderate TBI: Has nt cmpleted the minimum waiting perid seizure free and ff anticnvulsant medicatin. Des nt have a nrmal physical examinatin, neurlgical examinatin including neurphthalmlgical evaluatin, r neurpsychlgical test. Des nt have clearance frm a neurlgist wh understands the functins and demands f cmmercial driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have an annual medical examinatin. Page 165 f 260

Summary f Neurlgical Waiting Perids Seizure Waiting Perids The driver must cmplete the minimum waiting perid seizure free and ff anticnvulsant medicatin. Waiting Perid 10 years 5 years Diagnsis Histry f epilepsy. Viral encephalitis with early seizures. Single unprvked seizure, n identified acute change, may be distant cause (pssible earlier return t driving if nrmal neurlgical examinatin by a specialist in epilepsy wh understands the functins and demands f cmmercial driving, and the driver has a nrmal electrencephalgram). Bacterial meningitis and early seizures. 2 years Acute seizure with acute structural central nervus system insult. Based n risk f recurrence f primary cnditin. Table 5 - Seizure Waiting Perids Acute seizure with acute systemic/metablic illness. Other Neurlgical Event Waiting Perids The driver must cmplete the minimum waiting perid seizure free and ff anticnvulsant medicatin. Waiting Perid Diagnsis Mderate traumatic brain injury (TBI) with early seizures. 5 years Strke with risk fr seizures. Intracerebral r subarachnid hemrrhage with risk fr seizures. Mderate TBI withut early seizures. 2 years Surgically remved supratentrial r spinal tumrs. Transient ischemic attack, strke, r intracerebral r subarachnid hemrrhages with n risk fr seizures. 1 year Surgically-repaired arterivenus malfrmatins/aneurysm with n risk fr seizures. Page 166 f 260

Surgically remved infratentrial meningimas, acustic neurmas, pituitary adenmas, and benign spinal tumrs r ther benign extraaxial tumrs with n risk fr seizures. Infectins f the central nervus system (e.g., bacterial meningitis, viral encephalitis withut early seizures). Table 6 - Other Neurlgical Event Waiting Perids Musculskeletal (b)(1)(2)(7) 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 nndriving tasks as described in the driver rle sectin f the Federal Mtr Carrier Safety Administratin (FMCSA) Medical 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. Other jb tasks 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. Musculskeletal Regulatins 4 CF 391.41(b)(1)(2)(7) 49 CFR 391.41(b)(1) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Has n lss f a ft, a leg, a hand, r an arm, r has been granted a skill perfrmance evaluatin certificate pursuant t 391.49." 49 CFR 391.41(b)(2) "Has n impairment f: Page 167 f 260

(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 391.49." 49 CFR 391.41(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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely. This examinatin is fr public safety determinatin and is cnsidered by FMCSA t be a medical fitness fr duty" examinatin. As a medical examiner, yur fundamental bligatin during the musculskeletal assessment is t establish whether a driver has the musculskeletal strength, flexibility, dexterity, and balance t maintain cntrl f the vehicle and safely perfrm nndriving tasks. The examinatin is based n infrmatin prvided by the driver (histry), bjective data (physical examinatin), and additinal testing requested by the medical examiner. Yur 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. Key Pints fr Musculskeletal Examinatin During the physical examinatin, yu shuld ask the same questins as yu wuld fr any individual wh is being assessed fr musculskeletal cncerns. 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 Medical Examinatin Reprt frm includes health histry questins. Additinal questins shuld be asked t supplement infrmatin requested n the frm. Yu may ask abut musculskeletal symptms. 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 Yu must review and discuss with the driver any "yes" answers 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? Page 168 f 260

An injury r disease f the spine? Chrnic lw back pain? Recmmendatins Questins that yu may ask include Des the driver: Have physical limitatins caused by weakness, pain, r decreased mbility and range f mtin (nature and degree)? Use musculskeletal agents (effects and/r side effects)? Have mild, mderate, r severe chrnic musculskeletal pain (frequency and intensity)? Regulatins Yu must evaluate 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 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 medical examiner, 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 cngenital r acquired defects r spndyllisthesis and sclisis. Examinatin by a neurlgist r physiatrist wh understands the functins and demands f cmmercial driving may be required t assess the status f the disease. Hwever, as a medical examiner, it is yur respnsibility t determine certificatin status. Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative musculskeletal histry, including if available: Onset date and diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin used while driving, including ver-the-cunter medicatin. Any abnrmal finding(s), nting: Page 169 f 260

Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr. Overall requirements fr cmmercial drivers as well as the specific requirements in the jb descriptin f the driver shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Fixed Deficit f an Extremity When the lss f (hand, ft, leg, r arm) r a fixed impairment t an extremity may interfere with the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely, yu are respnsible fr determining if the driver is therwise medically fit t drive. A driver may be allwed t drive if the qualificatin requirements fr a Skill Perfrmance Evaluatin (SPE) certificate under 49 CFR 391.49 are met. Skill Perfrmance Evaluatin 4 CFR 391.49 See the Skill Perfrmance Evaluatin sectin f this handbk. NOTE: As a medical examiner, yu determine if the severity f a fixed deficit that is less than the whle hand is medically disqualifying unless the driver has an SPE certificate pursuant t 49 CFR 391.49. The SPE is applicable nly fr fixed deficits f the extremities. In rder t legally perate a CMV, the driver must carry an SPE certificate and a valid medical examiner's certificate. The driver is respnsible fr ensuring that bth certificates are renewed prir t expiratin. Waiting Perid N recmmended time frame The driver must be therwise medically fit fr duty befre certificatin r recertificatin in accrdance with 49 CFR 391.49. Decisin Maximum certificatin perid 2 years Recmmend t certify (accmpanied by an SPE) if: The driver has: A fixed deficit f an extremity and is therwise medically qualified at physical examinatin (required fr bth certificatin and recertificatin). A valid SPE certificate and dcumentatin f cmpliance with medical requirements (required fr recertificatin with a current SPE certificate). NOTE: The SPE applies nly t fixed deficits f the extremities, nt thse caused by a prgressive disease. T be certified, the driver with a deficit f an extremity caused by a prgressive disease must Page 170 f 260

meet 49 CFR 391.41 requirements, including adequate range f mtin, strength, grip, and prehensin t safely perate a CMV. Recmmend nt t certify if: The driver has: An impairment that affects the trs. Nt prvided prf f cmpliance with SPE certificatin requirements. A disqualifying limb impairment caused by a prgressive disease (e.g., multiple sclersis). NOTE: The SPE applies nly t fixed deficits f the extremities, nt thse caused by a prgressive disease. The driver with a deficit f an extremity caused by a prgressive disease must nt be certified if the driver cannt meet 49 CFR 391.41 requirements. Recmmend nt t certify if: Mnitring/Testing SPE initial and renewal applicatins als require a medical evaluatin summary cmpleted by either a bard qualified r bard certified physiatrist r rthpedic surgen. Yu shuld review the reprt at recertificatin fr any medical changes befre determining driver certificatin status. Fllw- up The driver shuld have at least biennial physical examinatins r mre frequently when indicated. The driver is respnsible fr maintaining current medical and SPE certificatin. Musculskeletal Tests Detectin f an undiagnsed musculskeletal finding during the physical examinatin may indicate the need fr further testing and examinatin t adequately assess medical fitness fr duty. Diagnstic-specific testing may be required t detect the presence and/r severity f the musculskeletal cnditin. The additinal testing may be rdered by the medical examiner, primary care physician, r musculskeletal specialist (e.g., rthpedic surgen, physiatrist). When requesting additinal evaluatin, the specialist must understand the rle and functin f a driver; therefre, it is helpful if yu include a descriptin f the rle f the driver and a cpy f the applicable medical standard(s) and guidelines with the request. Recrd Recrd additinal tests in the Medical Examinatin Reprt frm, "6. LABORATORY AND OTHER TEST FINDINGS" sectin and/r attach additinal test reprts. Table 7 - Medical Examinatin Reprt Frm: Labratry and Other Test Findings Page 171 f 260

Grip Strength Tests The Federal Mtr Carrier Safety Administratin des nt require any specific test fr assessing grip pwer. Examples f grip strength tests include: Dynammeter designed t measure grip strength. Sphygmmanmeter used as a screening test fr grip by having the applicant repeatedly squeeze the inflated cuff while nting the maximum deflectin n the gauge. REMEMBER: The driver must have sufficient grasp and prehensin t cntrl an versize steering wheel, shift gears using a manual transmissin, and maneuver a vehicle in crwded areas. Neurmuscular Diseases See Neurmuscular Diseases sectin f this handbk. Diabetes Mellitus The Center fr Disease Cntrl and Preventin (CDC) 2007 Natinal Diabetes Fact Sheet reprts the prevalence f diagnsed and undiagnsed diabetes mellitus in the United States, fr all ages, as: Ttal: 23.6 millin peple, r 7.8% f the ppulatin, have diabetes. Diagnsed: 17.9 millin peple. Undiagnsed: 5.7 millin peple. The mst cmmn frm f diabetes mellitus is Type 2 (adult nset r nn-insulin-dependent diabetes mellitus). Individuals with Type 2 diabetes mellitus: 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 the detectin and management f bth hyperglycemia and hypglycemia are imprtant aspects f the verall medical management f a persn with diabetes mellitus, the detectin and management f hypglycemia is mre relevant t safety cnsideratins, in the certificatin f the cmmercial mtr vehicle (CMV) driver, with diabetes mellitus. Bld Glucse Cntrl Sme f the factrs related t cmmercial driving that affect bld glucse cntrl include: Fatigue. Lack f sleep. Pr diet. Missed meals. Emtinal cnditins. Stress. Cncmitant illness. Page 172 f 260

These same factrs may hasten the need fr the driver with diabetes mellitus wh des nt use insulin t start insulin therapy. Prly cntrlled diabetes mellitus can result in serius, life-threatening health cnsequences. Hwever, with gd management f the disease prcess, a driver with diabetes mellitus 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 diabetes mellitus can lead t medical cnditins severe enugh t be disqualifying, such as neurpathy, retinpathy, and nephrpathy. Accelerated athersclersis is a majr cmplicatin f diabetes mellitus invlving the crnary, cerebral, and peripheral vessels. Individuals with diabetes mellitus are at increased risk fr crnary heart disease and have a higher incidence f painless mycardial infarctin than individuals wh d nt have diabetes mellitus. Preventing hypglycemia is the mst critical and challenging safety issue fr any driver with diabetes mellitus. Hypglycemia can ccur in individuals with diabetes mellitus 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 Federal Mtr Carrier Safety Administratin (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. Diabete Mellitus Regulatin 4 CF 391.41(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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the driver ability t perate a CMV safely. This examinatin is fr public safety determinatin and is cnsidered by FMCSA t be a medical fitness fr duty" examinatin. As a medical examiner, yur fundamental bligatin during the assessment f a driver with diabetes mellitus is t establish whether the driver is at an unacceptable risk fr sudden death r incapacitatin, thus endangering public safety. The risk may be assciated with the disease prcess and/r the treatment fr the disease. Page 173 f 260

The examinatin is based n infrmatin prvided by the driver (histry), bjective data (physical examinatin), and additinal testing requested by the medical examiner. Yur 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. Key Pints fr Diabetes Mellitus Examinatin Medical qualificatin f the driver with diabetes mellitus 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 Medical Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins abut diabetes mellitus symptms, treatment, and driver adjustment t living with a chrnic cnditin shuld be asked t supplement infrmatin requested n the frm. Regulatins Yu must review and discuss with the driver any "yes" answers Des the driver have diabetes mellitus r elevated bld glucse cntrlled by: Diet? Pills? Insulin? Other injectable medicatins? Recmmendatins Questins that yu may ask include 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, including has the driver had: One r mre ccurrences within last 12 mnths? Tw r mre ccurrences within last 5 years? Page 174 f 260

Regulatins Yu must evaluate 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? 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? Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the cnditin, if neglected, culd result in mre serius illness that might affect driving. Any additinal medical tests and evaluatin. REMEMBER: The diabetes qualificatin standard parameter is use f insulin, nt the diagnsis f diabetes mellitus. Advisry Criteria/Guidance Diabetes Mellitus The driver with diabetes mellitus wh des nt use insulin is eligible fr certificatin, unless the driver als has a disqualifying cmplicatin, cmrbidity, r fails t meet ne r mre f the ther standards fr qualificatin. Yu may chse t cnsult with the primary care prvider and/r specialist t adequately assess driver medical fitness fr duty. When requesting additinal evaluatin, including a cpy f the Medical Examinatin Reprt frm descriptin f the driver rle and medical standards is helpful. Remember that the prvider treating the driver is primarily cncerned with minimizing target rgan damage assciated with elevated levels f bld glucse. As a medical examiner, yur assessing any driver with diabetes mellitus fr the risk f a severe hypglycemic episde is the mst critical and challenging safety issue. Page 175 f 260

NOTE: If the driver with diabetes mellitus uses insulin, use the Federal Diabetes Exemptin Prgram and insulin therapy guidelines t determine certificatin status. See the Federal Diabetes Exemptin Prgram sectin f this dcument. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years NOTE: Because f the prgressive nature f diabetes mellitus, the Federal Mtr Carrier Safety Administratin (FMCSA) believes that 1 year maximum certificatin time is reasnable when the driver has a diagnsis f diabetes mellitus. Recmmend t certify if: The driver with diabetes mellitus: Meets all the physical qualificatin standards. Has a treatment plan that manages the disease and des nt: Include the use f insulin. Interfere with safe driving. Recmmend nt t certify if: The driver with diabetes mellitus has: In the last 12 mnths, experienced a hypglycemic reactin resulting in: Seizure. Lss f cnsciusness. Need f assistance frm anther persn. Perid f impaired cgnitive functin that ccurred withut warning. In the last 5 years, had recurring (tw r mre) disqualifying hypglycemic reactins (as described abve). Lss f psitin sensatin. Lss f pedal sensatin. Resting tachycardia. Orthstatic hyptensin. Diagnsis f: Peripheral neurpathy. Prliferative retinpathy (e.g., unstable prliferative r nn-prliferative). Page 176 f 260

Mnitring/Testing Urinalysis Glycsuria may indicate pr bld glucse cntrl. When urinalysis shws glycsuria, yu may elect t perfrm a finger stick test t btain a randm bld glucse. Bld Glucse Hemglbin A1c (HbA1c) greater than 10% is an indicatr f pr bld glucse cntrl. It is recmmended that yu btain further evaluatin r mnitr the driver mre frequently t determine if the disease prcess interferes with medical fitness fr duty and safe driving. Fllw- up The driver must have biennial physical examinatins. Yu may require the driver t have mre frequent examinatins, if indicated, t adequately mnitr the prgressin f the cnditin. NOTE: Encurage the driver with diabetes mellitus t participate in annual diabetes mellitus educatin. Incretin Mimetic An incretin mimetic, such as exenatide (Byetta), is used t imprve glycemic cntrl in peple with Type 2 diabetes by reducing fasting and pstprandial glucse cncentratins. An incretin mimetic is indicated as adjunctive therapy t individuals wh are taking metfrmin r a cmbinatin f ther ral agents. Use f an incretin mimetic in cnjunctin with a sulfnylurea has an increased risk f hypglycemia. Incretin mimetics are nt insulin and can be used withut an exemptin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year NOTE: The Federal Mtr Carrier Safety Administratin (FMCSA) recmmends frequent mnitring determined n a case-by-case basis. Recmmend t certify if: The driver with diabetes mellitus wh uses an incretin mimetic: Meets all the physical qualificatin standards. Has a treatment plan that manages the disease and des nt: Include the use f insulin. Have side effects that interfere with safe driving. Recmmend nt t certify if: As a medical examiner, yu believe that the nature and severity f the medical cnditin and/r the treatment f the driver endangers the safety and health f the driver and the public. Page 177 f 260

Mnitring/Testing FMCSA recmmends that a driver taking an incretin mimetic prvide a written statement frm the treating health care prfessinal. The written statement shuld: Describe driver tlerance t the medicatin. Indicate hw frequently the driver is mnitred fr adequate bld glucse cntrl. Include efficacy f treatment. Fllw- up FMCSA recmmends frequent mnitring f the driver wh is taking an incretin mimetic. Insulin Therapy Individuals wh require insulin fr cntrl f diabetes mellitus bld glucse levels als have treatment cnditins that can be adversely affected by the use f t much r t little insulin, r fd intake that is nt cnsistent with the insulin dsage. The administratin f insulin is a cmplicated prcess requiring insulin, syringe, needle, alchl spnge, and a sterile technique. Factrs related t lng-haul cmmercial mtr vehicle (CMV) peratins, such as fatigue, lack f sleep, pr diet, emtinal cnditins, stress, and cncmitant illness, cmpund the dangers. The Federal Mtr Carrier Safety Administratin (FMCSA) has cnsistently held that a driver with diabetes mellitus wh uses insulin des nt meet the minimum physical requirements f 49 CFR 391.41. Sme drivers with diabetes mellitus wh use insulin may be medically certified if the driver: Has r is eligible t apply fr a Federal diabetes exemptin. Has an FMCSA-issued letter that states the driver may be qualified by peratin f 49 CFR 391.64(a) (grandfathered status). NOTE: Prf f grandfathered status is the riginal letter frm 1996 granting the right t cntinue t drive as lng as the driver can meet physical qualificatin requirements. If a letter is nt prvided, yu may verify driver participatin in the study prgram and the driver can btain a new cpy f the letter by calling the FMCSA Exemptin Prgram Office at 703-448-3094. Hypglycemia Risk Preventing hypglycemia is the mst critical and challenging safety issue fr any driver with diabetes mellitus. Individuals wh use insulin are at an increased risk fr hypglycemic reactins. NOTE: 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 ccurs withut warning. Rescue Glucse In sme cases, hypglycemia can be self-treated by the ingestin f at least 20 grams f glucse tablets r carbhydrates. Cnsuming "rescue" glucse r carbhydrates may avert a hypglycemic reactin fr Page 178 f 260

less than a 2-hur perid. The driver with a diabetes exemptin must carry a surce f rapidly absrbable glucse while driving. Waiting Perid Minimum 1 mnth, if the driver with diabetes mellitus was previusly diagnsed and n treatment that did nt include the use f insulin Minimum 2 mnths, if the driver with diabetes mellitus is newly diagnsed and was nt n prir treatment Decisin Maximum certificatin 1 year Recmmend t certify if: The driver with diabetes mellitus: Meets all ther physical qualificatin requirements f 49 CFR 391.41(b) except fr use f insulin and: Recmmend nt t certify if: Has a Federal diabetes exemptin r is eligible t apply fr the exemptin. Was a participant in gd standing n March 31, 1996, in the Federal diabetes waiver study prgram and cntinues t meet all qualificatin requirements f 49 CFR 391.64(a). The driver with diabetes mellitus has: Other than the use f insulin t treat diabetes mellitus, any ther medical prblem r cnditin that prevents certificatin in accrdance with the qualificatin requirements f 49 CFR 391.41(b). In the last 12 mnths, had a severe hypglycemic reactin resulting in: Seizure. Lss f cnsciusness. Need f assistance frm anther persn. Perid f impaired cgnitive functin that ccurred withut warning. In the last 5 years, has had recurring (tw r mre) disqualifying severe hypglycemic reactins (as described abve). Lss f psitin sensatin. Lss f pedal sensatin. Resting tachycardia. Orthstatic hyptensin. Diagnsis f: Peripheral neurpathy that interferes with safe driving. Prliferative retinpathy (e.g., unstable prliferative r nn-prliferative). Page 179 f 260

Mnitring/Testing Annual Recertificatin Physical Examinatins The driver with a Federal diabetes exemptin shuld prvide yu with a cpy f the cmpleted Annual Diabetes Assessment Package that includes the: Endcrinlgist Annual Evaluatin Checklist. Exemptin requires evaluatin by a bard-certified r bard-eligible endcrinlgist. Visin Annual Evaluatin Checklist. Exemptin requires evaluatin by an phthalmlgist r ptmetrist. The driver diagnsed with diabetic retinpathy is required t have an eye examinatin by an phthalmlgist. The grandfathered driver shuld prvide a cpy f the endcrinlgist reprt addressing the requirements listed in 49 CFR 391.64(a). Urinalysis Glycsuria may indicate pr bld glucse cntrl. When urinalysis shws glycsuria, yu may elect t perfrm a finger stick test t btain a randm bld glucse. Bld Glucse Pr bld glucse cntrl may indicate a need fr further evaluatin r mre frequent mnitring t determine if the disease prcess interferes with safe driving. Bld Glucse Mnitring Guidelines The Federal Diabetes Exemptin Prgram guidelines fr bld glucse mnitring include using a device that recrds the results fr later review and measuring bld glucse level: Befre driving. Every 2 t 4 hurs while driving. Bld glucse levels that remain within the 100 milligrams per deciliter (mg/dl) t 400 mg/dl range are generally cnsidered safe fr cmmercial driving. NOTE: Yu shuld review and cnsider the findings f the mst recent specialist evaluatin reprts and bld glucse mnitring dcumentatin befre determining if the driver is medically fit fr duty. Fllw- up The driver must have an annual physical examinatin. NOTE: The driver is respnsible fr maintaining bth a current Medical Examiner s Certificate and Federal diabetes exemptin. Oral Hypglycemics Hypglycemic drugs taken rally are frequently prescribed fr persns with diabetes mellitus t help stimulate natural bdy prductin f insulin. If diabetes mellitus can be cntrlled by the use f ral medicatin and diet, an individual may be cnsidered fr driver certificatin using the physical qualificatin requirements f 49 CFR 391.41. NOTE: If the driver with diabetes mellitus uses insulin, use the Federal Diabetes Exemptin Prgram and insulin therapy guidelines t determine certificatin status. Page 180 f 260

Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver with diabetes mellitus wh uses an ral hypglycemic medicatin: Meets all the physical qualificatin standards. Has a treatment plan that manages the disease and des nt: Include the use f insulin. Have side effects that interfere with safe driving. Recmmend nt t certify if: As a medical examiner, yu believe that the nature and severity f the medical cnditin and/r the treatment f the driver endangers the safety and health f the driver and the public. Mnitring/Testing Nt applicable. Fllw- up The driver shuld have biennial physical examinatins. Yu may require the driver t have mre frequent physical examinatins, if indicated, t adequately mnitr driver medical fitness fr duty. Other Diseases The fundamental questin when deciding if a cmmercial driver shuld be certified is whether the driver has a cnditin that s increases the risk f sudden death r incapacitatin 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 caseby-case basis, use yur clinical skills and knwledge f the Federal Mtr Carrier Safety Administratin (FMCSA) physical qualificatin standards t evaluate the verall medical fitness fr duty f the driver. The medical advisry criteria fr 49 CFR 391.41(b)(9) includes examples f hw medical cnditins might interfere with peratin f a cmmercial mtr vehicle (CMV). Yu are expected t assess the nature and severity f the medical cnditin and determine certificatin utcmes n a case-by-case basis and 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." Page 181 f 260

"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. Other Diseases Regulatin 4 CF 391.41(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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the driver ability t perate a CMV safely. This examinatin is fr public safety determinatin and is cnsidered by FMCSA t be a "medical fitness fr duty" examinatin. As the medical examiner, yur fundamental bligatin during the medical assessment is t establish whether a driver has any disease r disrder 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 medical examiner. Yur 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. Key Pints fr Other Diseases The FMCSA Medical Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins shuld be asked, t supplement infrmatin requested n the frm, t adequately assess medical fitness fr duty f the driver. Yu shuld ask abut and dcument any ther cnditins that might impact the ability t safely perate a CMV. Regulatins Yu must review and discuss with the driver any "yes" answers Any illness r injury in the last 5 years? Kidney disease, dialysis? Liver disease? Digestive prblems? Page 182 f 260

Recmmendatins Questins that yu may ask include Des the driver have: Medical therapy that requires mnitring? Any current limitatin? Regulatins Yu must evaluate On examinatin, des the driver have: Abnrmal urinalysis? Enlarged liver? Enlarged spleen? Masses? Bruits? Hernia? Significant abdminal wall muscle weakness? Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal cardivascular tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr. Overall requirements fr cmmercial drivers, as well as the specific requirements in the jb descriptin f the driver, shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Hernia The Medical Examinatin Reprt frm physical examinatin sectin includes checking fr hernia fr bth the abdmen and viscera bdy system and the geniturinary system. Page 183 f 260

If a hernia causes discmfrt r the diagnsis suggests that the cnditin might interfere with the cntrl and safe peratin f a cmmercial mtr vehicle (CMV), further testing and evaluatin may be required t determine driver certificatin status. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the etilgy is cnfirmed, and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Recmmend t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver des nt endanger the safety and health f the driver and the public. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the safety and health f the driver and the public. Mnitring/Testing Yu may, n a case-by-case basis, btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up The driver must have at least biennial medical examinatins. Nephrpathy Diabetic nephrpathy accunts fr a significant number f the new cases f end-stage renal disease. The first sign f nephrpathy cmmnly is the develpment f persistent prteinuria. End-stage renal disease fllws sme time later. Whether nephrpathy is a disqualifying factr shuld be determined n the basis f the degree f disease prgressin and the assciated impact n driver ability t functin. The prevalence f nephrpathy is strngly related t the duratin f diabetes mellitus. After 15 years f living with diabetes mellitus, the frequency f nephrpathy is higher amng individuals wh use insulin than with individuals wh d nt use insulin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the etilgy is cnfirmed, and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Page 184 f 260

Recmmend t certify if: The driver: Meets all the physical qualificatin standards. Has a treatment plan that manages the disease and des nt interfere with safe driving. Recmmend nt t certify if: As the medical examiner, yu believe that the nature and severity f the medical cnditin f the driver endangers the safety and health f the driver and the public. Mnitring/Testing Urinalysis - An abnrmal urinalysis, including but nt limited t prteinuria, may indicate sme degree f renal dysfunctin. Yu may, n a case-by-case basis, btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. When requesting additinal evaluatin frm a specialist, the specialist must understand the rle and functin f a driver. Therefre, including cpies f the Medical Examinatin Reprt frm descriptin f the driver rle and the applicable medical standard(s) and guidelines with the request is helpful. Fllw- up The driver must have biennial medical examinatins. Yu may require mre frequent examinatins, if indicated, t adequately mnitr the prgressin f the cnditin. Urinalysis Yu are required t perfrm a urinalysis (dip stick) as a part f every driver certificatin and recertificatin medical examinatin and t recrd test results fr: Specific gravity. Prtein. Bld. Glucse. Prteinuria, hematuria, r glycsuria may be an indicatin fr further testing t rule ut any underlying medical prblem. Yu shuld advise the driver f any abnrmal findings and when indicated, encurage the driver t seek primary care prvider evaluatin, particularly if an abnrmal urinalysis culd indicate the presence f a medical cnditin that if left untreated culd result in a serius illness that might affect driving. When an abnrmal urinalysis is indicative f a medical cnditin that endangers the safety and health f the driver and the public, yu shuld nt certify the driver until the etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Psychlgical Disrders (b)(9) Safe and effective peratin f a cmmercial mtr vehicle (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. Page 185 f 260

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. 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 and have an increased crash rate. Psychlgical Regulatin 4 CF 391.41(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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect 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. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a "medical fitness fr duty" examinatin. As a medical examiner, yur fundamental bligatin during the psychlgical assessment is t establish whether a driver has a psychlgical disease r disrder that increases the risk fr peridic, residual, r insidius nset f cgnitive, behaviral, and/r functinal impairment that endangers public safety. The examinatin is based n infrmatin prvided by the driver (histry), bjective data (physical examinatin), and additinal testing requested by the medical examiner. Yur 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. Page 186 f 260

Key Pints fr Psychlgical Examinatin During the physical examinatin, yu shuld ask the same questins as yu wuld fr any individual wh is being assessed fr psychlgical cncerns. The FMCSA Medical 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 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 mre in-depth mental health evaluatin. Regulatins Yu must review and discuss with the driver any "yes" answers 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? Recmmendatins Yu shuld bserve driver presentatin and interactin Des the driver display any f the fllwing: Inapprpriate dress? Suspiciusness? Evasiveness? Threatening behavir? Hstility? Distractibility? Flat affect r n emtinal expressin? Unusual r bizarre ideas? Auditry r visual hallucinatins? Dishnesty? Omissin f imprtant infrmatin? Recmmendatins Ask the driver Have yu ever thught f hurting yurself? Have yu ever thught f suicide? Have yu ever 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? Page 187 f 260

D yu ever have prblems with yur cncentratin r memry? Have yu ever heard vices that ther peple dn't seem 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? 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 Yu must evaluate On examinatin, des the driver have: Tremr? Enlarged liver and/r spleen? Signs f alchlism r prblem drinking? Drug abuse? Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a cmmercial vehicle safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal psychlgical tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr and t have gd judgment, impulse cntrl, and prblem-slving skills. Overall requirements fr cmmercial drivers as well as the specific requirements in the jb descriptin f the driver shuld be deciding factrs in the certificatin prcess. Page 188 f 260

Advisry Criteria/Guidance 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. Antidepressant Therapy Guidelines recmmend case-by-case assessment f drivers treated with antidepressant medicatin. Evidence indicates that sme antidepressant drugs significantly interfere with skills perfrmance and that these medicatins vary widely in the degree f impact. With lng-term use f antidepressants, many drivers will develp a tlerance t the sedative effects. Yur evaluatin must cnsider bth the specific medicine used and the pertinent characteristics f the patient. First generatin antidepressants have cnsistently been shwn t interfere with safe driving. First generatin antidepressants include tricyclics such as amitriptyline (Elavil) and imipramine (Tfranil). Secnd generatin antidepressants have fewer side effects and are generally safe; hwever, these medicatins can still interfere with safe driving and require case-by-case evaluatin. Secnd generatin antidepressants include selective sertnin reuptake inhibitrs (SSRIs) such as fluxetine (Przac) and sertraline (Zlft); sertnin and nrepinephrine reuptake mdulatrs such as venlafaxine (Effexr); and unicyclic aminketnes such as buprpin (Wellbutrin). Yu shuld cnsider the underlying reasn fr treatment when determining certificatin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the medicatin has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: As the medical examiner, yu believe: Nature and severity f the underlying cnditin des nt interfere with safe driving. Page 189 f 260

Effects r side effects f medicatin use while perating a cmmercial mtr vehicle d nt endanger the safety f the driver and the public. Recmmend nt t certify if: The driver: Uses a first generatin antidepressant. Has treatment effects r side effects that interfere with safe driving. NOTE: Federal Mtr Carrier Safety Administratin recmmendatins favr nt certifying the driver wh uses a first generatin tricyclic antidepressant stating that "nly under exceptinal circumstances wuld cntinuus use f amitriptyline be acceptable fr a cmmercial driver." Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving t evaluate: Dse, plasma cncentratin, and duratin f drug therapy. Severity f the underlying mental disrder. Fllw- up The driver shuld have annual medical examinatins. Antipsychtic Therapy Antipsychtic drugs include typical and atypical neurleptics. These agents are used t treat schizphrenia, psychtic md disrders, and sme persnality disrders. Sme cases f nausea and chrnic pain are als treated with antipsychtic agents. Many f the cnditins are assciated with behavirs and symptms such as impulsiveness, disturbances in perceptin and cgnitin, and an inability t sustain attentin. Often the behavirs and symptms are nly partially crrected by neurleptics. Neurleptics can cause a variety f side effects that can interfere with driving, such as mtr dysfunctin that affects crdinatin and respnse time, sedatin, and visual disturbances (especially at night). Waiting Perid N recmmended time frame. Yu shuld nt certify the driver until the medicatin has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Page 190 f 260

Recmmend t certify if: As the medical examiner, yu believe: Nature and severity f the underlying cnditin des nt interfere with safe driving. Effects f medicatin use while perating a cmmercial mtr vehicle des nt endanger the safety f the driver and the public. Recmmend nt t certify if: The driver has: Disqualifying underlying cnditin. Treatment side effects that interfere with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving t evaluate: Dse, plasma cncentratin, and duratin f drug therapy. Severity f the underlying mental disrder. Fllw- up The driver shuld have annual medical examinatins. Anxilytic and Sedative Hypntic Therapy Anxilytic drugs used fr the treatment f anxiety disrders and t treat insmnia are termed sedative hypntics. Studies have demnstrated that benzdiazepines, the mst cmmnly used anxilytics and sedative hypntics, impair skills perfrmance in pharmaclgically active dsages. The effects f benzdiazepines n skills perfrmance generally als apply t virtually all nnbenzdiazepines sedative hypntics, althugh the impairment is typically less prfund. Hwever, barbiturates and ther sedative hypntics related t barbiturates cause greater impairment in perfrmance than benzdiazepines. Epidemilgical studies indicate that the use f benzdiazepines and ther sedative hypntics are prbably assciated with an increased risk f autmbile crashes. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the medicatin has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 2 years Page 191 f 260

Recmmend t certify if: The driver uses: Hypntic, if the medicatin is: Shrt-acting (half-life f less than 5 hurs). The lwest effective dse. Used fr a shrt perid f time (less than 2 weeks). Nn-sedating anxilytic. Recmmend nt t certify if: The driver: Uses a sedating anxilytic. Has symptms r side effects that interfere with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have at least biennial medical examinatins r mre frequently if indicated. Central Nervus System Stimulant Therapy Psychiatric uses f central nervus system (CNS) stimulants (e.g., dextramphetamine, methylphenidate, and pemline) include primary treatment f narclepsy and adult attentin deficit hyperactivity disrder (ADHD), bth f which are assciated with psychmtr deficits related t sleepiness r hyperactivity. CNS stimulants may als be used as adjuncts t antidepressants. CNS stimulants imprve perfrmance n simple tasks, but nt n tasks requiring cmplex intellectual functins. Fr sme cnditins (e.g., fatigue, brain damage, adult ADHD), lw dses f CNS stimulants can enhance: Vigilance and attentin. Perfrmance f simple tasks (nt cmplex intellectual functins). Befre qualifying a driver with ADHD wh is using a CNS stimulant: Request evaluatin frm the treating prvider. Verify the diagnsis f adult ADHD. Use cautin when determining the side effects f medicatin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the medicatin has been shwn t be adequate/effective, safe, and stable. Page 192 f 260

Decisin Maximum certificatin 1 year Recmmend t certify if: The driver has: Nn-disqualifying underlying cnditin (e.g., adult ADHD). N drug-induced impairment. N tendency t increase the dse. Recmmend nt t certify if: The driver has: Disqualifying underlying cnditin (e.g., narclepsy). Treatment side effects that interfere with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving t evaluate: Dse, plasma cncentratin, and duratin f drug therapy. Severity f the underlying mental disrder. Fllw- up The driver shuld have annual medical examinatins. Electrcnvulsive Therapy Electrcnvulsive therapy (ECT) is smetimes used t treat depressin. ECT prduces an acute rganic mental syndrme characterized by cnfusin, disrientatin, and lss f shrt-term memry even with lw-dse, brief pulse, unilateral treatment. Clinical experience has shwn that acute side effects usually reslve rapidly and almst invariably within a few mnths. Waiting Perid Minimum 6 mnths symptm free fllwing a curse f ECT NOTE: If mre than ne waiting perid applies (because f multiple cardiac cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Page 193 f 260

Decisin Recmmend t certify if: The driver: Cmpletes the waiting perid. Has a cmprehensive evaluatin frm an apprpriate mental health prfessinal wh understands the functins and demands f cmmercial driving. Is nt underging maintenance ECT. Tlerates treatment withut disqualifying side effects (e.g., sedatin r impaired crdinatin). Recmmend nt t certify if: The driver has: Maintenance ECT. Treatment side effects that interfere with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have annual medical examinatins. Lithium Therapy Lithium (Eskalith) is used fr the treatment f biplar and depressive disrders. Studies suggest that there is little evidence f lithium interfering with driver skill perfrmance. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Recmmend t certify if: The driver: Is asymptmatic. Has lithium levels that are maintained in the therapeutic range. Has n impairment that interferes with safe driving. Page 194 f 260

Recmmend nt t certify if: The driver has: Disqualifying underlying cnditin. Disqualifying symptms. Lithium levels that are nt in the therapeutic range. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving t evaluate: Dse, plasma cncentratin, and duratin f drug therapy. Severity f the underlying mental disrder. Fllw- up The driver shuld have annual medical examinatins. Adult Attentin Deficit Hyperactivity Disrder Children wh had attentin deficit hyperactivity disrder (ADHD) ften cntinue t shw signs f the disrder int adulthd. Essential features f adult ADHD include age-inapprpriate levels f inattentin, impulsiveness, and hyperactivity. Symptms include md lability, lw frustratin tlerance, and explsiveness. Risks t safe driving assciated with adult ADHD include cmrbid antiscial r brderline persnality disrder and/r ther disrders, side effects f medicatin, and a high incidence f substance abuse; hwever, a significant percentage f individuals with adult ADHD shw a mderate t marked degree f imprvement n central nervus system stimulant medicatin. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver: Cmplies with treatment prgram. Tlerates treatment withut disqualifying side effects (e.g., sedatin r impaired crdinatin). Has a cmprehensive evaluatin frm an apprpriate mental health prfessinal wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: Page 195 f 260

The driver has: An active psychsis. Prminent negative symptms, including: Substantially cmprmised judgment. Attentinal difficulties. Suicidal behavir r ideatin. Persnality disrder that is repeatedly manifested by vert, inapprpriate acts. Side effects that interfere with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have annual medical examinatins. Biplar Md Disrder Md disrders are characterized by their pervasiveness and symptms that interfere with the ability f the individual t functin scially and ccupatinally. The tw majr grups f md disrders are biplar and depressive disrders. Biplar disrder is characterized by ne r mre manic episdes and is usually accmpanied by ne r mre depressive episdes. The nset f manic episdes may be sudden r gradual. Symptms include excessively elevated, expansive, r irritable mds. During a manic episde, judgment is frequently diminished, and there is an increased risk f substance abuse. Sme episdes may present with delusins r hallucinatins. Treatment fr biplar mania may include lithium and/r anticnvulsants t stabilize md and antipsychtics when psychsis manifests. Symptms f a depressive episde include lss f interest and mtivatin, pr sleep, appetite disturbance, fatigue, pr cncentratin, and indecisiveness. A severe depressin is characterized by psychsis, severe psychmtr retardatin r agitatin, significant cgnitive impairment (especially pr cncentratin and attentin), and suicidal thughts r behavir. In additin t the medicatin used t treat mania, antidepressants may be used t treat biplar depressin. Other psychiatric disrders, including substance abuse, frequently cexist with biplar disrder. NOTE: Cyclthymia is a mild frm f biplar disrder that causes brief episdes f depressin r elevated md, but typically des nt cause marked impairment. Treatment may include medicatin. Determinatin is nt based n diagnsis alne. The actual ability t drive safely and effectively shuld nt be determined slely by diagnsis but instead by an evaluatin fcused n functin and relevant histry. Waiting Perid Minimum 6 mnths symptm free fllwing a nnpsychtic majr depressin unaccmpanied by suicidal behavir Minimum 1 year symptm free fllwing a severe depressive episde, a suicide attempt, r a manic episde Page 196 f 260

NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver: Cmpletes an apprpriate symptm-free waiting perid. Cmplies with treatment prgram. Tlerates treatment withut disqualifying side effects (e.g., sedatin r impaired crdinatin). Has a cmprehensive evaluatin frm an apprpriate mental health prfessinal wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Active psychsis. Prminent negative symptms, including: Substantially cmprmised judgment. Attentinal difficulties. Suicidal behavir r ideatin. Persnality disrder that is repeatedly manifested by vert inapprpriate acts. Treatment side effects that interfere with safe driving. Mnitring/Testing At least every 2 years the driver with a histry f a majr md disrder shuld have evaluatin and clearance frm a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving. Advise the certified driver with a majr md disrder t reprt any manic r severe majr depressive episde within 30 days f nset t the driver's emplyer, medical examiner, r apprpriate health care prfessinal and t seek medical interventin. Fllw- up The driver shuld have annual medical examinatins. Majr Depressin Majr depressin cnsists f ne r mre depressive episdes that may alter md, cgnitive functining, behavir, and physilgy. Symptms may include a depressed r irritable md, lss f interest r pleasure, scial withdrawal, appetite and sleep disturbance that lead t weight change and fatigue, restlessness and agitatin r malaise, impaired cncentratin and memry functining, pr judgment, and suicidal thughts r attempts. Hallucinatins and delusins may als develp, but they are less cmmn in depressin than in manic episdes. Page 197 f 260

Mst individuals with majr depressin will recver; hwever, sme will relapse within 5 years. A significant percentage f individuals with majr depressin will cmmit suicide; the risk is the greatest within the first few years fllwing the nset f the disrder. Althugh precipitating factrs fr depressin are nt clear, many patients experience stressful events in the 6 mnths preceding the nset f the episde. In additin t antidepressants, ther drug therapy may include anxilytics, antipsychtics, and lithium. Prphylactic treatment may prevent r shrten future episdes. Electrcnvulsive therapy is als used t treat sme cases f severe depressin. Determinatin is nt based n diagnsis alne. The actual ability t drive safely and effectively shuld nt be determined slely by diagnsis but instead by an evaluatin fcused n functin and relevant histry. Waiting Perid Minimum 6 mnths symptm free fllwing a nnpsychtic majr depressin unaccmpanied by suicidal behavir Minimum 1 year symptm free fllwing a severe depressive episde, a suicide attempt, r a manic episde NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver: Cmpletes an apprpriate symptm-free waiting perid. Cmplies with treatment prgram. Tlerates treatment withut disqualifying side effects (e.g., sedatin r impaired crdinatin). Has a cmprehensive evaluatin frm an apprpriate mental health prfessinal wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Active psychsis. Prminent negative symptms, including: Substantially cmprmised judgment. Attentinal difficulties. Suicidal behavir r ideatin. Persnality disrder that is repeatedly manifested by vert, inapprpriate acts. Treatment side effects that interfere with safe driving. Page 198 f 260

Mnitring/Testing At least every 2 years the driver with a histry f a majr md disrder shuld have evaluatin and clearance fr cmmercial driving frm a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving. Advise the certified driver with a majr md disrder t reprt any manic r severe majr depressive episde within 30 days f nset t the driver's emplyer, medical examiner r apprpriate health care prfessinal and t seek medical interventin. Fllw- up The driver shuld have annual medical examinatins. Persnality Disrders Any persnality disrder characterized by excessive, aggressive, r impulsive behavirs warrants further inquiry fr risk assessment t establish whether such traits are serius enugh t adversely affect behavir in a manner that interferes with safe driving. A persn is medially unqualified if the disrder is severe enugh t have repeatedly been manifested by vert acts that interfere with safe peratin f a cmmercial vehicle. NOTE: Alchl and drug dependency and abuse are prfund risk factrs in the presence f persnality disrders. Determinatin is nt based n diagnsis alne. The actual ability t drive safely and effectively shuld nt be determined slely by diagnsis but instead by an evaluatin fcused n functin and relevant histry. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the etilgy is cnfirmed and treatment has been shwn t be adequate/effective, safe, and stable. Decisin Maximum certificatin 1 year Recmmend t certify if: The driver: Cmplies with treatment prgram. Tlerates treatment withut disqualifying side effects (e.g., sedatin r impaired crdinatin). Has a cmprehensive evaluatin frm an apprpriate mental health prfessinal wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: An active psychsis. Page 199 f 260

Prminent negative symptms, including substantially cmprmised judgment, attentinal difficulties, suicidal behavir r ideatin, r a persnality disrder that is repeatedly manifested by vert, inapprpriate acts. Treatment side effects that interfere with safe driving. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsult with a mental health specialist, such as a psychiatrist r psychlgist, t adequately assess driver medical fitness fr duty. Fllw- up The driver shuld have annual medical examinatins. Schizphrenia and Related Psychtic Disrders Schizphrenia is the mst severe cnditin within the spectrum f psychtic disrders. Characteristics f schizphrenia include psychsis (e.g., hearing vices r experiencing delusinal thughts), negative r deficit symptms (e.g., lss f mtivatin, apathy, r reduced emtinal expressin), and cmprmised cgnitin, judgment, and/r attentin. There is als an increased risk fr suicide. Individuals with chrnic schizphrenia shuld nt be cnsidered medically qualified fr cmmercial driving. Related cnditins include: Schizphrenifrm disrder. Brief reactive psychsis. Schizaffective disrder. Delusinal disrder. Risks fr Cmmercial Driving Clinical experience shws that a persn wh is actively psychtic may behave unpredictably in a variety f ways. Fr example, a persn wh is hearing vices may receive a cmmand t d smething harmful r dangerus, such as self-mutilatin. Delusins r hallucinatins may lead t vilent behavir. Mrever, antipsychtic therapy may cause sedatin and mtr abnrmalities (e.g., muscular rigidity r tremrs) and impair crdinatin, particularly as the medicatin is being initiated and dses are adjusted. Except fr a cnfirmed diagnsis f schizphrenia, determinatin may nt be based n diagnsis alne. The actual ability t drive safely and effectively shuld nt be determined slely by diagnsis but instead by an evaluatin fcused n functin and relevant histry. Waiting Perid Minimum 6 mnths symptm free if a brief reactive psychsis r schizphrenifrm disrder Minimum 1 year symptm free if any ther psychtic disrder NOTE: If mre than ne waiting perid applies (because f multiple cnditins r ther cmrbid diseases), examine the driver fr certificatin after the cmpletin f the lngest waiting perid. Decisin Maximum certificatin 1 year Page 200 f 260

Recmmend t certify if: The driver: Cmpletes an apprpriate symptm-free waiting perid. Cmplies with treatment prgram. Tlerates treatment withut disqualifying side effects (e.g., sedatin r impaired crdinatin). Has a cmprehensive evaluatin frm an apprpriate mental health prfessinal wh understands the functins and demands f cmmercial driving. Recmmend nt t certify if: The driver has: Diagnsis f schizphrenia. Active psychsis. Prminent negative symptms, including: Substantially cmprmised judgment. Attentinal difficulties. Suicidal behavir r ideatin. Persnality disrder that is repeatedly manifested by vert, inapprpriate acts. Treatment side effects that interfere with safe driving. NOTE: Chrnic schizphrenia is usually a clear-cut cnditin. Individuals with this cnditin tend t be severely incapacitated and frequently lack the cgnitive skills necessary fr steady emplyment, may have impaired judgment and pr attentin, and have a high risk fr suicide. Mnitring/Testing At least every 2 years, the driver with a histry f mental illness with psychtic features shuld have evaluatin and clearance fr cmmercial driving frm a mental health specialist, such as a psychiatrist r psychlgist, wh understands the functins and demands f cmmercial driving. Advise the certified driver with a majr md disrder t reprt any manic r severe majr depressive episde within 30 days f nset t the driver's emplyer, medical examiner, r apprpriate health care prfessinal and t seek medical interventin. Fllw- up The driver shuld have annual medical examinatins. Drug Abuse and Alchlism 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 plysubstance 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. Page 201 f 260

Alchl and ther drug dependencies and abuse are prfund risk factrs assciated with persnality disrders that may 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 (e.g., alchl enhances hypglycemic effects f sulfnylureas). 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 1991. See the FMCSA Drug and Alchl Prgram at http://www.fmcsa.dt.gv/safety-security/drugalchl/index.aspx fr mre infrmatin abut the regulatins and guidelines gverning CMV drivers. Drug Abuse and Alchlism Regulatins 4 CF 391.41(b)(12)(13) 49 CFR 391.41(b)(12)i)(ii)(A)(B) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Des nt use a cntrlled substance identified in 21 CFR 1308.11 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." 49 CFR 391.41(b)(13) "Has n current clinical diagnsis f alchlism." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely. This examinatin is fr public safety determinatin and is cnsidered by FMCSA t be a medical fitness fr duty exam. As a medical examiner, 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, r 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. The examinatin is based n infrmatin prvided by the driver (histry), bjective data (physical examinatin), and additinal testing requested by the medical examiner. Yur assessment shuld reflect physical, psychlgical, and envirnmental factrs. Page 202 f 260

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. Key Pints fr Medical Assessment fr Drug Abuse and/r Alchlism During the physical examinatin, yu shuld ask the same questins as yu wuld fr any individual wh is being assessed fr psychlgical r behavir cncerns. The FMCSA Medical Examinatin Reprt frm includes health histry questins and physical examinatin check lists. Additinal questins shuld be asked t supplement infrmatin requested n the frm. 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. Regulatins Yu must review and discuss with the driver any "yes" answers Des the driver use: Alchl, regularly and frequently? Narctic r habit-frming drugs? Recmmendatins Questins that yu may ask include 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? 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. Page 203 f 260

Regulatins Yu must evaluate On examinatin, des the driver have signs f alchlism, prblem drinking, r drug abuse, including: Tremr. Enlarged liver. Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin as sn as pssible, particularly if the untreated cnditin culd result in mre serius illness that might affect driving. Any additinal drug abuse r alchl screening tests and evaluatin. REMEMBER: The Medical Review Officer versees the drug and alchl testing prcess. Medical fitness fr duty includes the ability t perfrm strenuus labr and t have gd judgment, impulse cntrl, and prblem-slving skills. Overall requirements fr cmmercial drivers as well as the specific requirements in the driver rle jb descriptin shuld be deciding factrs in the certificatin prcess. Abut 49 CF 382 Alchl and Drug Rules The purpse f this part is t establish prgrams designed t help prevent crashes and injuries resulting frm the misuse f alchl r use f cntrlled substances by drivers f cmmercial mtr vehicles (CMVs). Key Pints Abut 49 CFR Part 382 Wh must be tested? All drivers, including part-time, hlding a cmmercial driver's license (CDL) and perating CMVs (greater than 26,000 cmbined grss vehicle weight rating, r transprting mre than 16 passengers, r placarded hazardus materials) n the public radways must be U.S. Department f Transprtatin (DOT) drug and alchl tested. This means any driver required t pssess a CDL, including: Drivers emplyed by Federal, State, and lcal gvernment agencies. Owner peratrs. Equivalently licensed drivers frm freign cuntries. Fr-hire mtr carriers. NOTE: Drivers wh nly perate CMVs n private prperty nt pen t the public d nt require testing. Page 204 f 260

When is drug and/r alchl testing required? Pre-emplyment: Drug testing is required; hwever, a driver may be exempted frm testing if the driver was in a testing prgram within the last 30 days and tested within the last 6 mnths r in a prgram fr the previus 12 mnths. Alchl testing is nt required; hwever, the emplyer may require alchl testing befre the driver can perfrm safety-sensitive functins. The emplyer may make the jb ffer cntingent upn passing an alchl test. Pst-accident drug and/r alchl testing is required fr all fatal crashes and when the driver is cited fr a mving traffic vilatin. Reasnable suspicin testing is cnducted when a trained supervisr r cmpany fficial bserves behavir r appearance that is characteristic f drug and/r alchl misuse. Randm drug and/r alchl testing is cnducted n a randm, unannunced basis just befre, during, r just after perfrmance f safety-sensitive functins. Return-t-duty and fllw-up testing is cnducted when an individual wh has vilated the prhibited drug and/r alchl cnduct standards returns t perfrming safety-sensitive duties. Emplyer respnsibilities include: Implementing and cnducting drug and alchl testing prgrams. Prviding a list f substance abuse prfessinals (SAPs). Ensuring that the driver wh is returning t a safety-sensitive psitin has cmplied with SAP recmmendatins. Cnducting fllw-up testing t mnitr that the driver is cmpliant with DOT alchl cnduct guidelines and abstaining frm unauthrized drug use. Emplyer respnsibilities d nt include: Prviding SAP evaluatins. Paying fr driver SAP evaluatin, educatin, r treatment. Fr mre infrmatin see Federal Mtr Carrier Safety Administratin Web site http://www.fmcsa.dt.gv/rules-regulatins/tpics/drug/engtesting.htm. Advisry Criteria/Guidance Alchlism Except where abslute criteria exist (i.e., a current clinical diagnsis f alchlism), as a medical examiner, yu make the final determinatin as t whether the driver meets the Federal Mtr Carrier Safety Administratin (FMCSA) medical standards fr driver certificatin. Use whatever tls r additinal assessments yu feel are necessary. If the driver shws signs f alchlism, have the driver cnsult a specialist fr further evaluatin. If yu believe immediate testing fr alchl is warranted, cntact FMCSA r cntact the emplyer f the driver directly fr infrmatin n cntrlled substances and alchl testing under Part 382 f the Federal Mtr Carrier Safety Regulatins. Page 205 f 260

A driver MUST submit t alchl testing if there is reasnable suspicin that the U.S. Department f Transprtatin (DOT) prhibitins cncerning alchl are vilated. Suspicin MUST be based n specific bservatins cncerning driver behavir, speech, r bdy dr. Interpretatin fr 49 CFR 391.41 When an interstate driver tests psitive fr alchl r cntrlled substances under Part 382, the driver is nt required t be medically re-examined r t btain a new medical examiner s certificate prvided the driver is seen by a SAP wh evaluates the driver and des nt make a clinical diagnsis f alchlism. The SAP prvides the driver with dcumentatin allwing the driver t return t wrk. If the SAP determines that alchlism exists, the driver is nt qualified t drive a cmmercial mtr vehicle in interstate cmmerce. The ultimate respnsibility rests with the mtr carrier t ensure the driver is medically qualified and t determine whether a new medical examinatin shuld be cmpleted. Waiting Perid N recmmended time frame Yu shuld nt certify the driver until the driver has successfully cmpleted cunseling and/r treatment. Decisin Maximum certificatin 2 years Recmmend t certify if: The driver with a histry f alchlism has: N residual disqualifying physical impairment. Successfully cmpleted cunseling and/r treatment. N current disqualifying alchl-related disrders. D nt t certify if: The driver has: A current clinical diagnsis f alchlism. Signs f a current alchlic illness and/r nn-cmpliance with DOT alchl cnduct guidelines. An alchl-related unstable physical cnditin, regardless f the time element. Nt met return-t-duty requirements. NOTE: Onging vluntary attendance at self-help grups (e.g., 12-step prgrams) fr maintenance f recvery is nt disqualifying. Mnitring/Testing Yu may n a case-by-case basis btain additinal tests and/r cnsultatin t adequately assess driver medical fitness fr duty. Fllw- up N specific fllw up is required. Page 206 f 260

Drug Abuse All drug test results are reviewed and interpreted by a physician wh is certified as a medical review fficer (MRO). When there is a psitive result, the MRO cntacts the driver and cnducts an interview t determine if there is an alternative medical explanatin fr finding drugs in the urine specimen. The MRO ntifies the emplyer nly after determining that a psitive test result was caused by unauthrized driver use f a cntrlled substance. All urine specimens are tested fr: Marijuana. Ccaine. Amphetamines. Opiates. Phencyclidine (PCP). A driver MUST be remved frm safety-sensitive duty when the driver has a psitive drug test result caused by the unauthrized use f a cntrlled substance. T be returned t safety-sensitive duties the driver MUST: Be evaluated by a substance abuse prfessinal (SAP). Cmply with recmmended rehabilitatin. Have a negative result n a return-t-duty drug test. Waiting Perid N recmmended time frame Yu shuld nt certify the driver fr the duratin f the prhibited drug(s) use and until a secnd examinatin shws the driver is free frm the prhibited drug(s) use and has cmpleted any recertificatin requirements. T be returned t safety-sensitive duties the driver MUST: Be evaluated by a SAP. Cmply with recmmended rehabilitatin. Have a negative result n a return-t-duty drug test. Decisin Maximum certificatin 2 years Recmmend t certify if: The driver with a histry f drug abuse has: N residual disqualifying physical cnditin. Prf f successful cmpletin f return-t-duty requirements. Page 207 f 260

D nt t certify if: The driver uses: Schedule I cntrlled substances. Amphetamines. Narctics. Any ther habit-frming drug fr which the exceptin guidelines d nt apply. Methadne (regardless f the reasn fr the prescriptin). Marijuana (even if in a State that allws medicinal use). NOTE: Onging vluntary attendance at self-help grups (e.g., 12-step prgrams) fr maintenance f recvery is nt disqualifying. Mnitring/Testing Yu have the ptin t certify fr a perid f less than 2 years if mre frequent mnitring is required. Fllw- up The driver shuld have at least biennial medical examinatins r mre frequently if indicated. Medicatins/Drug Use 49 CFR 391.41(b)(12) 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. 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, yu are instructed t discuss cmmn prescriptins and OTC medicatins relative t the side effects and hazards f these medicatins while driving. In additin, educate the driver t read warning labels n all medicatins. Medicatins/Drug Use Regulatin 49 CFR 391.41(b)(12) "A persn is physically qualified t drive a cmmercial mtr vehicle if that persn Page 208 f 260

Des nt use a cntrlled substance identified in 21 CFR 1308.11 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." Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely. This examinatin is fr public safety determinatin and is cnsidered by the Federal Mtr Carrier Safety Administratin (FMCSA) t be a "medical fitness fr duty" examinatin. As the medical examiner, yur fundamental bligatin is t establish whether a driver uses ne r mre medicatins and supplements that have cgnitive r physical effects r side effects that interfere with safe driving, 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 medical examiner. Yur 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. Key Pints fr Medicatins Use Examinatin During the physical examinatin, yu shuld ask the driver t prvide a cmplete histry f medicatin use, including OTC medicatins and fd and herbal supplements. The FMCSA Medical 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 the medicatin while driving. Regulatins Yu must review and discuss with the driver any "yes" answers Des the driver use medicatins t: Treat cardivascular disease? Reduce hypertensin? Cntrl bld glucse level? Oral hypglycemics? Insulin (regardless f rute)? Cntrl seizures r treat epilepsy? Treat nervus r psychiatric disrders? Did the driver list all medicatins (including OTC medicatins) used regularly r recently? Page 209 f 260

Recmmendatins Questin that yu may ask include Des the driver experience: Dizziness r light-headedness? Hyptensin? Sedatin? Depressed md? Cgnitive deficit? Decreased reflex respnses? Unsteadiness? Regulatins Yu must evaluate On examinatin, des the 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 hyptensin)? Imprtant cnsideratins fr medicatin use while driving Des the medicatin: Indicate the presence f 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 (e.g., decreased libid). 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 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 new medicatin r cmbining medicatins while driving. Page 210 f 260

Recrd Regulatins Yu must dcument discussin with the driver abut Any affirmative histry, including: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including OTC medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Necessary steps t crrect the cnditin if apprpriate, r reasns fr disqualificatin. Any additinal tests and evaluatin. REMEMBER: Medical fitness fr duty includes the ability t perfrm strenuus labr and t have gd judgment, impulse cntrl, and prblem-slving skills. Overall requirements fr cmmercial drivers as well as the specific requirements in the driver rle jb descriptin shuld be deciding factrs in the certificatin prcess. Advisry Criteria/Guidance Abut 21 USC Sec. 812 Schedules f Cntrlled Substances 49 CFR 391.41(b)(12) identifies driver use f Schedule I drugs as medically disqualifying. The 1970 Cmprehensive Drug Abuse Preventin and Cntrl Act prvides the framewrk fr the current Drug Enfrcement Administratin (DEA) drug schedules. There are five schedules f cntrlled substances, I, II, III, IV, and V. The drug schedules are based n addictin ptential and medical use but nt n side effects. The lists are updated annually. NOTE: The advisry criteria first directs yu t 21 CFR 1308.11 TITLE 21 FOOD AND DRUGS CHAPTER 13 DRUG ABUSE PREVENTION AND CONTROL SUBCHAPTER I CONTROL AND ENFORCEMENT Part B Authrity T Cntrl; Standards and Schedules. This regulatin describes the rules and prcedures used t establish and maintain the 21 USC Sec. 812 cntrlled substance lists. Key Pints Abut 21 USC Sec. 812 Schedule I These drugs have n currently accepted medical use in the United States, have a high abuse ptential, and are nt cnsidered safe, even under medical supervisin. These substances include many piates, piate derivatives, and hallucingenic substances. Herin and marijuana are examples f Schedule I drugs. The exceptin criteria f 49 CFR 41(b)(12)(ii) des nt apply t any Schedule I substance. NOTE: The driver taking medical marijuana cannt be certified. Schedule II These drugs have currently accepted medical uses but have a high abuse ptential that may lead t severe psychlgical r physical dependence. Schedule II drugs include piids, depressants, and Page 211 f 260

amphetamines. The piids in Schedule II include natural piids (e.g., mrphine) and synthetic piids (e.g., OxyCntin). NOTE: Interpretatin fr 49 CFR 391.41- Methadne is a habit-frming narctic which can prduce drug dependence and is nt an allwable drug fr peratrs f cmmercial mtr vehicles (CMV). Schedules III - V These drugs have decreasing ptential fr abuse than preceding schedules. Abuse may lead t mderate r lw physical dependence r high psychlgical dependence. Schedule III drugs include tranquilizers. Schedule IV drugs include drugs such as chlrhydrl and phenbarbital. Schedule V drugs have the lwest ptential fr abuse and include narctic cmpunds r mixtures. Side effects are nt part f the DEA schedule rating criteria. Therefre, a substance can have little risk fr addictin and abuse but still have side effects that interfere with driving ability. See Abut 49 CFR 382 Alchl and Drug Rules sectin f this handbk. Page 212 f 260

Appendix A: Medical Examinatin Reprt Frm T print a sample Medical Examinatin Reprt frm, visit: http://www.fmcsa.dt.gv/dcuments/safetyprgrams/medical-reprt.pdf Medical Examinatin Reprt Frm - Page 1 The first page f the Medical Examinatin Reprt frm is fr recrding Driver Infrmatin and Health Histry. The driver cmpletes these sectins. Driver Infrmatin A cmplete physical examinatin is required fr new certificatin and recertificatin. Verify that the date f the examinatin is accurate because this is used t calculate the expiratin date. Any individual can request and be given a Federal Mtr Carrier Safety Administratin physical examinatin. A persn must be at least 21 years f age t perate a cmmercial mtr vehicle (CMV) in interstate cmmerce. A persn perating a CMV in interstate cmmerce must be medically examined, carry an riginal r cpy f the medical examiner s certificate while driving, and be currently licensed (cmmercial r nncmmercial). Health Histry The health histry is an essential part f the driver physical examinatin. Are there limitatins resulting frm a current r past medical cnditin? Are there symptms that indicate additinal testing r evaluatin is needed? Discuss the safety implicatins f effects and/r side effects f prescriptin and ver-the-cunter medicatins, supplements, and herbs. Ensure that the driver signs and dates the Medical Examinatin Reprt frm. By signing the frm, the driver certifies that the infrmatin and histry are cmplete and true. The driver signature als acknwledges that prviding inaccurate r false infrmatin r mitting infrmatin culd invalidate the medical examiner s certificate. A civil penalty may be levied under 49 U.S.C. 521(b)(2)(b) against the driver wh prvides a false r intentinally incmplete medical histry. Everything abve the driver signature shuld be cmpleted by the driver. As a medical examiner, yu must clarify yes answers. Dcument the significant findings f the health histry in the cmments sectin belw the signature f the driver. Medical Examinatin Reprt Frm - Page 2 The results f the fur required tests: visin, hearing, bld pressure/pulse, and urinalysis are recrded n the secnd page f the Medical Examinatin Reprt frm. Abnrmal test results may disqualify a driver r indicate that additinal evaluatin and/r testing are needed. Drug and alchl testing are nt required fr the driver physical examinatin unless findings indicate they are needed t determine medical fitness fr duty. Visin The medical examiner r a licensed phthalmlgist r ptmetrist can examine and certify visin test results. Page 213 f 260

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 and distinguish traffic signals and devices shwing the standard red, amber, and green clrs. When crrective lenses are used t meet visin qualificatin requirements, the crrective lenses must be used while driving. A driver with mncular visin, wh is therwise medically qualified, may apply fr a Federal visin exemptin. The driver with a Federal visin exemptin may be certified fr up t 1 year. Yu may certify the driver wh meets visin qualificatin requirements, with r withut the use f crrective lenses, fr up t 2 years. Hearing T qualify, the driver must meet the hearing requirement f either the frced whisper test r the audimetric test in ne ear. The requirement fr the: Frced whisper test is t first perceive a frced whispered vice, in ne ear, at nt less than five feet. Audimetric test is t have an average hearing lss, in ne ear, less than r equal t 40 decibels (db). The driver wh wears a hearing aid t meet the hearing qualificatin requirement must wear a hearing aid while driving. Bld Pressure/Pulse Recrd pulse rate and rhythm n the Medical Examinatin Reprt Frm. The cardivascular recmmendatins fr certificatin using the JNC-6 stages f hypertensin are summarized in the Medical Examinatin Reprt frm table. Bld pressure (BP) readings are defined as: 140-159/90-99 = Stage 1 hypertensin. 160-179/100-109 = Stage 2 hypertensin. Greater than r equal t 180/110 = Stage 3 hypertensin. The driver with hypertensin and BP less than r equal t 139/89 may be certified fr up t 1 year. Cnfirm an elevated BP by a secnd elevated BP later in the examinatin. The driver with stage 1 r stage 2 hypertensin may be certified in accrdance with the cardivascular recmmendatins, which take int cnsideratin knwn hypertensin histry. Disqualify a driver with stage 3 hypertensin. Urinalysis Recrd the test results f the required dipstick urinalysis (UA) in the Labratry and Other Medical Test Findings sectin f the Medical Examinatin Reprt frm. The dipstick urinalysis must measure specific Page 214 f 260

gravity and test fr prtein, bld, and glucse in the urine. Psitive test results may indicate that additinal evaluatin is needed. Attach cpies f additinal test results and interpretatin reprts t the Medical Examinatin Reprt frm. Medical Examinatin Reprt Frm - Page 3 Recrd the physical examinatin and certificatin status n the third page f the Medical Examinatin Reprt frm. Physical Examinatin The physical examinatin shuld be as thrugh as described in the Medical Examinatin Reprt frm, at a minimum. Nte any abnrmal finding, including the safety implicatin, even if nt disqualifying. Infrm the driver f any abnrmal findings and as needed advise the driver t btain fllw-up evaluatin. Physical examinatin may indicate the need fr additinal evaluatin and/r tests. Specialists, such as cardilgists and endcrinlgists, may perfrm additinal medical evaluatin, but it is the medical examiner wh decides if the driver is medically qualified t drive. Dcument the certificatin decisin, including the ratinale fr any decisin that des nt cncur with the recmmendatins. Certificatin and Dcumentatin Certificatin Status Dcument the certificatin decisin in the space prvided fr certificatin status. There are tw pssible utcmes: the driver is certified and issued a medical examiner's certificate r the driver is disqualified and is nt issued a medical examiner's certificate. Certify the driver The driver meets all the standards The maximum length f time a driver can be medically certified is 2 years. The driver wh must wear crrective lenses, a hearing aid, r have a Skill Perfrmance Evaluatin certificate may be certified fr up t 2 years when there are n ther cnditins that require peridic mnitring. The driver meets the standards but has a cnditin that requires frequent mnitring (and certificatin) Certify fr less than 2 years as needed t mnitr cntinued medical fitness fr duty. Federal exemptins and sme Federal Mtr Carrier Safety Administratin guidelines specify annual medical examinatins. Disqualify the driver The driver des nt meet the standards D nt issue a medical examiner's certificate. Discuss the disqualificatin decisin with the driver, including what the driver can d t meet the Federal qualificatin requirements fr cmmercial drivers. Certificatin and recertificatin ccur nly when the medical examiner determines that the driver is medically fit fr duty in accrdance with Federal qualificatin requirements fr cmmercial drivers. Medical Examiner's Certificate Prvide the medical examiner's certificate t the qualified driver. Ensure that the date entered is the date f the physical examinatin. The expiratin date shuld be cnsistent with the Medical Examinatin Reprt frm certificatin status and cannt exceed 2 years frm the date f the examinatin. The driver Page 215 f 260

must sign the medical examiner's certificate. The certificate expires at midnight n the date f expiratin. There is n grace perid. The driver must carry a valid medical examiner's certificate when perating a cmmercial vehicle. The mtr carrier is als required t maintain a cpy f the medical examiner's certificate. The certificate can be the riginal r a phtcpy, and can be reduced in size (usually wallet-sized). Laminatin is prhibited in sme States. 49 CFR 391.43 REGULATION AMENDMENT 73 FR 73127, Dec. 1, 2008 There are nw tw paragraphs in 49 CFR 391.43(g): (g)(1) If the medical examiner finds that the persn examined is physically qualified t perate a cmmercial mtr vehicle in accrdance with 391.41(b), the medical examiner shuld cmplete a certificate in the frm prescribed in paragraph (h) f this sectin and furnish the riginal t the persn wh was examined. The examiner may prvide a cpy t a prspective r current emplying mtr carrier wh requests it. (g)(2) Fr all drivers examined, the medical examiner shuld retain a cpy f the Medical Examinatin Reprt at least 3 years frm the date f the examinatin. If the driver was certified as physically qualified, then the medical examiner shuld als retain the medical certificate as well fr at least 3 years frm the date the certificate was issued. Page 216 f 260

Appendix B: Federal Exemptin Prgrams 49 CFR 381.300 What is an exemptin? "(a) An exemptin is temprary regulatry relief frm ne r mre FMCSR given t a persn r class f persns subject t the regulatins, r wh intend t engage in an activity that wuld make them subject t the regulatins. (b) An exemptin prvides the persn r class f persns with relief frm the regulatins fr up t tw years, and may be renewed. (c) Exemptins may nly be granted frm ne r mre f the requirements cntained in the fllwing parts and sectins f the FMCSRs... (c)(3) Part 391 Qualificatins f Drivers." Federal Visin Exemptin Prgram The FMCSA Visin Exemptin Prgram is fr mncular visin. The visin exemptin is issued fr a maximum f 2 years and is renewable. The driver must be therwise qualified under 49 CFR 391.41(b)(1-13) r hld anther valid medical exemptin t legally perate a cmmercial mtr vehicle in interstate cmmerce. Prvisins f the visin exemptin include an annual medical examinatin and an eye examinatin by an phthalmlgist r an ptmetrist. At the annual recertificatin examinatin, the driver shuld present the current visin exemptin and a cpy f the specialist eye examinatin reprt. Certify the qualified driver fr 1 year and issue a medical examiner's certificate with the "accmpanied by" exemptin checkbx marked and write "visin" t identify the type f Federal exemptin. The mtr carrier is respnsible fr ensuring that the driver has the required dcumentatin befre driving a cmmercial vehicle. The driver is respnsible fr carrying bth the visin exemptin and the medical examiner's certificate while driving and keeping bth current. Qualified by Operatin f 49 CFR 391.64: "Grandfathered" Prir t the implementatin f the Federal Visin Exemptin Prgram, FMCSA cnducted an initial visin study prgram that ran frm 1992 t 1996. At the cnclusin f that study, 2,656 drivers received a netime letter cnfirming participatin in the study and granting a cntinued exemptin frm the mncular visin requirement, as lng as the driver is therwise medically fit fr duty and can meet the visin qualificatin requirements with the ne eye. The driver wh was grandfathered must have an annual medical examinatin and an eye examinatin by an phthalmlgist r ptmetrist. There are very few remaining drivers frm that prgram. At the annual medical examinatin, the driver shuld present t the medical examiner the letter identifying the driver as a participant in the visin study prgram and a cpy f the specialist eye examinatin reprt. Certify the qualified driver fr 1 year and issue a medical examiner's certificate with the "Qualified by peratin f 49 CFR 391.64" checkbx marked. Page 217 f 260

Federal Diabetes Exemptin Prgram Abut the Federal Diabetes Exemptin Prgram Backgrund Prir t the implementatin f the Federal Diabetes Exemptin Prgram, the Federal Mtr Carrier Safety Administratin (FMCSA) cnducted a waiver study prgram cncerning cmmercial mtr vehicle (CMV) peratin by drivers with insulin-cntrlled diabetes. A small number f the drivers wh participated in the study and were participants in gd standing n March 31, 1996, were prvided a letter frm FMCSA that grandfathered them an exemptin frm standard 49 CFR 391.41(b)(3), by peratin f 49 CFR 391.64(a), as lng as they were in cmpliance with the requirements. These drivers are gverned by 49 CFR 391.64(a) and must prvide the letter frm FMCSA as prf f their grandfathered status befre yu issue a Medical Examiner's Certificate t the driver. On September 3, 2003, FMCSA published a Ntice f Final Dispsitin annuncing the decisin t issue exemptins t the diabetes mellitus prhibitin under 49 CFR 391.41(b)(3). This prgram allws sme drivers wh meet all medical standards and guidelines, ther than the use f insulin, t be medically certified and perate a CMV if the driver als meets the parameters fr issuance f a Federal diabetes exemptin. The 2003 Ntice explained that in cnsidering exemptins, FMCSA must ensure that the issuance f diabetes exemptins will nt be cntrary t the public interest, and that the exemptin achieves an acceptable level f safety. Respnsibilities As a medical examiner, yu are respnsible fr determining if the driver is therwise medically fit fr duty and issuing a Medical Examiner's Certificate that indicates the driver is certified ONLY IF the driver has a diabetes exemptin. The Federal Diabetes Exemptin Prgram is respnsible fr determining if the driver meets prgram requirements and fr issuing the diabetes exemptin. The mtr carrier is respnsible fr ensuring that the driver has a current medical examiner's certificate and diabetes exemptin befre allwing the driver t perate a cmmercial vehicle. The driver is respnsible fr carrying bth the Medical Examiner's Certificate and the diabetes exemptin while driving and keeping bth certificates current. The Federal diabetes exemptin must be renewed every 2 years. The driver must als cmply with prgram requirements that include: Annual: CMV driver medical qualificatin examinatin. Endcrinlgist evaluatin. Ophthalmlgist/ptmetrist evaluatin. Diabetes mellitus educatin. Mnitring bld glucse. NOTE: Althugh yu, as a medical examiner, are nt invlved in the Diabetes Exemptin Prgram mnitring, it is helpful fr yu t understand the requirements. The driver must prvide a quarterly evaluatin checklist frm his/her endcrinlgist thrughut the 2-year perid r risk lsing the exemptin. Page 218 f 260

The Safe, Accuntable, Flexible, Efficient Transprtatin Equity Act A Legacy fr Users (SAFETEA- LU), August 10, 2005, eliminated the driving experience requirement. Fr mre infrmatin, review the Diabetes Exemptin Applicatin at http://www.fmcsa.dt.gv/dcuments/safetyprgrams/diabetes/diabetes-exemptin-package.pdf. Please direct questins cncerning Driver Exemptin Prgrams t medicalexemptins@dt.gv r call 1-703- 448-3094. Relevance t Driving The Center fr Disease Cntrl and Preventin (CDC) 2007 Natinal Diabetes Fact Sheet (http://www.cdc.gv/features/dsdiabetes/) reprts that in adults, type 1 diabetes accunts fr 5 10% f all diagnsed cases f diabetes. Individuals with type 1 diabetes mellitus: Are distinguished by a virtual lack f insulin prductin and ften severely cmprmised cunterregulatry mechanisms. Must have insulin replacement therapy. May lack bld glucse cntrl cunter-regulatry mechanisms. Althugh hypglycemia can ccur in nn-insulin-treated diabetes mellitus, it is mst ften assciated with insulin-treated diabetes mellitus. Mild hypglycemia causes rapid heart rate, sweating, weakness, and hunger, while severe hypglycemia causes headache and dizziness. 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 ccurs withut warning. Health Histry and Physical Examinatin General Purpse f Health Histry and Physical Examinatin The general purpse f the histry and physical examinatin is t detect the presence f physical, mental, r rganic cnditins f such character and extent as t affect the driver ability t perate a CMV safely. This examinatin is fr public safety determinatin and is cnsidered by FMCSA t be a medical fitness fr duty" examinatin. As a medical examiner, yur fundamental bligatin during the assessment f a driver with diabetes mellitus wh uses insulin is t establish whether the driver meets all medical standards and guidelines in accrdance with 49 CFR 391.41(b)(1-13), ther than the use f insulin t treat diabetes. The examinatin is based n infrmatin prvided by the driver (minimum 5-year histry), bjective data (physical examinatin), and additinal testing requested by the medical examiner. Yur 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. Key Pints fr Examinatin When the Driver Has Diabetes Mellitus and Uses Insulin This physical examinatin starts the Federal Diabetes Exemptin Prgram applicatin prcess. The medical examiner evaluatin guidelines (http://nrcme.fmcsa.dt.gv/dcuments/dmcertlet.pdf) stipulate Page 219 f 260

that the medical examiner review the 5-year medical histry f the driver. The driver must prvide a 5- year medical histry fr yur review befre yu determine certificatin status. The FMCSA Medical Examinatin Reprt frm includes health histry questins and physical examinatin checklists. Additinal questins shuld be asked t supplement infrmatin requested n the frm. Yu shuld ask abut and dcument diabetes mellitus symptms, bld glucse mnitring, insulin treatment, and histry f hypglycemic episdes. It is yur respnsibility t determine if the driver meets all medical standards and guidelines, ther than diabetes, in accrdance with 49 CFR 391.41(b)(1-13). Any ther medical prblems r cnditins that prevent a driver being certified by the medical examiner must be crrected BEFORE the driver submits an applicatin t the Federal Diabetes Exemptin Prgram. Regulatins Yu must review and discuss with the driver any "yes" answers Des the driver have diabetes mellitus r elevated bld glucse cntrlled by: Diet? Pills? Insulin? Dsage? Rute? Frequency? Recmmendatins Questins that yu may ask include Des the driver: Newly started n insulin have dcumentatin f cmpletin f minimum waiting perid? With a valid Federal diabetes exemptin have dcumentatin f cmpliance with prgram requirements fr specialist evaluatin? Rutinely mnitr bld glucse level and have device recrd fr review? 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? Carry rescue glucse while driving? NOTE: When the driver has a psitive histry fr severe hypglycemic reactins, ask abut ccurrences, including has the driver had: One r mre ccurrences within last 12 mnths? Tw r mre ccurrences within last 5 years? Page 220 f 260

Regulatins Yu must evaluate 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? 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? State-issued Medical Waivers and Exemptins It is imprtant that as a medical examiner yu distinguish between intrastate waivers/exemptins and Federal diabetes exemptins fr insulin-treated diabetes mellitus. Recrd Regulatins Yu must dcument discussin with the driver abut: Any affirmative histry, including if available: Onset date, diagnsis. Medicatin(s), dse, and frequency. Any current limitatin(s). Ptential negative effects f medicatin use, including ver-the-cunter medicatins, while driving. Any abnrmal finding(s), nting: Effect n driver ability t perate a CMV safely. Advice t take the necessary steps t crrect the cnditin as sn as pssible particularly if the cnditin, if neglected, culd result in mre serius illness that might affect driving. Any additinal medical tests and evaluatin. When dcumenting the certificatin f the driver with diabetes mellitus wh uses insulin, ensure that the Medical Examinatin Reprt frm peridic mnitring interval and the Medical Examiner's Certificate expiratin date agree and d nt exceed 1 year. When the driver has r must btain a Federal diabetes exemptin: Mark the "accmpanied by a " exemptin checkbx. Write "Federal diabetes" n the line. Circle "exemptin." Page 221 f 260

Figure 24 - Medical Examinatin Reprt: Federal Diabetes Exemptin In the case f the driver wh has dcumentatin f having been a participant in gd standing in the Federal diabetes study n March 31, 1996, mark the "Qualified by peratin f 49 CFR 391.64" checkbx. NOTE: Prf f grandfathered status is the riginal letter frm 1996 granting the right t cntinue t drive as lng as the driver can meet physical qualificatin requirements. If a letter is nt prvided, yu may verify driver participatin in the study prgram and the driver can btain a new cpy f the letter by calling the FMCSA Exemptin Prgram Office at 703-448-3094. Figure 25 - Medical Examinatin Reprt: Grandfathered Status REMEMBER: The diabetes qualificatin standard parameter is use f insulin, nt the diagnsis f diabetes mellitus. Page 222 f 260

Appendix C: Skill Perfrmance Evaluatin Fixed Deficit f an Extremity When the lss f (hand, ft, leg, r arm) r a fixed impairment t an extremity may interfere with the ability f the driver t perate a cmmercial mtr vehicle (CMV) safely, yu are respnsible fr determining if the driver is therwise medically fit t drive. A driver may be allwed t drive if the qualificatin requirements fr a Skill Perfrmance Evaluatin (SPE) certificate under 49 CFR 391.49 are met. NOTE: As a medical examiner, yu determine if the severity f a fixed deficit that is less than the whle hand is medically disqualifying unless the driver has an SPE certificate pursuant t 49 CFR 391.49. The SPE is applicable nly fr fixed deficits f the extremities. In rder t legally perate a CMV, the driver must carry an SPE certificate and a valid medical examiner's certificate. The driver is respnsible fr ensuring that bth certificates are renewed prir t expiratin. Waiting perid N recmmended time frame The driver must be therwise medically fit fr duty befre certificatin r recertificatin in accrdance with 49 CFR 391.49. Decisin Maximum certificatin perid 2 years Recmmend t certify (accmpanied by an SPE) if: The driver has: A fixed deficit f an extremity and is therwise medically qualified at physical examinatin (required fr bth certificatin and recertificatin). A valid SPE certificate and dcumentatin f cmpliance with medical requirements (required fr recertificatin with a current SPE certificate). NOTE: The SPE applies nly t fixed deficits f the extremities, nt thse caused by a prgressive disease. T be certified, the driver with a deficit f an extremity caused by a prgressive disease must meet 49 CFR 391.41 requirements, including adequate range f mtin, strength, grip, and prehensin t safely perate a CMV. Recmmend nt t certify if: The driver has: An impairment that affects the trs. Nt prvided prf f cmpliance with SPE certificatin requirements. A disqualifying limb impairment caused by a prgressive disease (e.g., multiple sclersis). NOTE: The SPE applies nly t fixed deficits f the extremities, nt thse caused by a prgressive disease. The driver with a deficit f an extremity caused by a prgressive disease must nt be certified if the driver cannt meet 49 CFR 391.41 requirements. Page 223 f 260

Recmmend nt t certify if: Mnitring/Testing SPE initial and renewal applicatins als require a medical evaluatin summary cmpleted by either a bard qualified r bard certified physiatrist r rthpedic surgen. Yu shuld review the reprt at recertificatin fr any medical changes befre determining driver certificatin status. Fllw- up The driver shuld have at least biennial physical examinatins r mre frequently when indicated. The driver is respnsible fr maintaining current medical and SPE certificatin. Page 224 f 260

Appendix D: Cardivascular Recmmendatin Tables The first publicatin f the Cardivascular Recmmendatin Tables ccurred in the Octber 2002, Cardivascular Advisry Panel Guidelines fr the Medical Examinatin f Cmmercial Mtr Vehicle Drivers, FMCSA-MCP-02-002. T review this publicatin, visit: http://www.fmcsa.dt.gv/facts-research/research-technlgy/publicatins/cardi.htm Preface The Federal Mtr Carrier Safety Administratin (FMCSA) has an nging prcess fr reviewing all Federal medical standards and guidelines used t determine driver medical fitness fr duty. These tables will be updated when changes are made t FMCSA medical standards and guidelines. All prpsed changes t the medical standards are subject t public ntice-and-cmment rulemaking. As part f its review prcess, FMCSA cnsiders medical evidence reprts, medical expert panel (MEP) pinin, and Medical Review Bard (MRB) recmmendatins. FMCSA als cnsiders ther factrs such as feasibility and impact. These tables d nt include recmmendatins that have been submitted t FMCSA fr cnsideratin but nt adpted by FMCSA. Hwever, FMCSA psts cpies f the medical evidence reprt executive summaries and MEP recmmendatins n the FMCSA Web page Reprts - Hw Medical Cnditins Impact Driving fund at http://www.fmcsa.dt.gv/rules-regulatins/tpics/mep/mep-reprts.htm Reprts f MRB prceedings are psted n the MRB Web site at http://www.mrb.fmcsa.dt.gv/prceedings.aspx, and the MRB public meeting schedule at http://www.mrb.fmcsa.dt.gv/. Medical examiners may submit questins r cmments t the FMCSA Office f Medical Prgrams by sending an email t fmcsamedical@dt.gv. Page 225 f 260

ANEURYSMS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 145 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Abdminal Artic Aneurysm (AAA) Evaluate fr assciated cardivascular diseases. Aneurysm < 4.0 cm. Yes, if asymptmatic. Annual Aneurysm 4.0 t <5.0 cm. Ultrasund t identify change in size. Yes if: Asymptmatic; Cleared by vascular specialist. Annual Ultrasund fr change in size. N, if: Symptmatic; Surgery recmmended by vascular specialist. Yes if: At least 3 mnths after surgical repair. Cleared by cardivascular specialist. Annual Aneurysm > 5.0 cm. N. Thracic Aneurysm Aneurysms f ther vessels Evaluate fr assciated cardivascular diseases. Yes if: At least 3 mnths after surgical repair. Cleared by cardivascular specialist. N, if >3.5cm. Yes if: At least 3 mnths after surgical repair. Cleared by cardivascular specialist. Assess fr risk f rupture N and fr assciated cardivascular diseases. Yes if: At least 3 mnths after surgical repair. Cleared by cardivascular specialist. Annual Annual Annual Page 226 f 260

AORTIC CONGENITAL HEART DISEASE 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 122 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Bicuspid Artic Valve May result in artic stensis r regurgitatin (see sectin n Valvular Diseases), artic rt enlargement, artic aneurysm frmatin and artic rupture. See sectin n Valvular Diseases. N if: Artic transverse diameter > 5.5 cm. See sectin n Valvular Diseases. Yes if: Surgical interventin successfully perfrmed. Annual Subvalvular Artic Mild = favrable Yes if: Annual Stensis Has ptential fr prgressin. N valvular abnrmality r hypertrphic cardimypathy. Evaluatin by cardilgist knwledgeable in adult cngenital heart disease is require. Mderate r severe = unfavrable. N if: Symptmatic and mean pressure gradient >30 mm Hg. Yes if: At least 3 mnths after successful surgical resectin when cleared by cardilgist knwledgeable in cngenital heart disease. Discrete Supravalvular Unfavrable prgnsis N, unless surgery. Artic Stensis due t assciated crnary and artic disrder. Yes if: At least 3 mnths pst surgical interventin; Cleared by cardilgist knwledgeable in adult cngenital heart disease. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease required, including echcardigram. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease is recmmended. Page 227 f 260

AORTIC CONGENITAL HEART DISEASE (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 122 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Marfan Syndrme Cardivascular disrders are the majr cause f mrbidity and mrtality including risk f sudden death. Yes if: N cardivascular invlvement. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease required including artic rt imaging and echcardigraphy. N if: Any artic rt enlargement; mderate r mre severe artic regurgitatin; > mild mitral regurgitatin related t mitral valve prlapse; LV dysfunctin with EF <40% and n assciated valve disease. Page 228 f 260

AORTIC REGURGITATION 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 79 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Mild Artic Regurgitatin Yes, if asymptmatic. Annual Echcardigram every 2 t 3 years. Mderate Artic Yes if: Annual Regurgitatin Nrmal LV functin; N r mild LV enlargement. Echcardigram every 2 t 3 years. Severe Artic Regurgitatin Yes if: Asymptmatic; Nrmal LV functin (EF = 50%); LV dilatatin (LVEDD < 60mm, LVESD < 50mm). Every 6 mnths. Echcardigram every 6 t 12 mnths. If LVEDD = 60mm r LVESD = 50mm. Every 4-6 mnths. Echcardigram every 4-6 mnths if n surgery perfrmed. N if: Symptms, Unable t cmplete Bruce prtcl Stage II, Reduced EF < 50%, LV dilatatin LVEDD > 70mm r LVESD > 55mm. EF=Ejectin fractin LVESD=Left ventricular end-systlic dimensin LVEDD=Left ventricular end-diastlic dimensin Yes if: Annual Valve surgery and at least 3 mnths pst surgery. Asymptmatic; cleared by cardilgist. Page 229 f 260

AORTIC STENOSIS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 78 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Mild Artic Stensis (AVA > 1.5 cm 2 ) Mderate Artic Stensis (AVA >1.0-1.5 cm 2 ) If symptms are cnsistent with artic stensis but calculated valve area suggests mild artic stensis, the severity f the stensis and an alternative explanatin fr symptms needs t be reassessed. Yes, if asymptmatic. Yes, if asymptmatic. Yes if: At least 3 mnths after surgery. N if: Angina, Heart failure, Syncpe; Atrial fibrillatin; LV dysfunctin with EF <50%; Thrmbemblism. Annual Echcardigram every 5 years. Annual Echcardigram every 1 t 2 years. Annual Severe Artic Stensis (AVA <1.0 cm 2 ) N, irrespective f symptms r LV functin. AVA = artic valve area Yes, if at least 3 mnths after surgery. Annual Page 230 f 260

ATRIAL SEPTAL DEFECTS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 124 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Atrial Septal Defect Small ASD = favrable. (ASD): Ostium Secundum Mderate t large ASD = unfavrable. Yes if: Asymptmatic. N if: Symptms f dyspnea, palpitatins r a paradxical emblus; Pulmnary hypertensin; Right-t-left shunt; r Pulmnary t systemic flw rati > 1.5 t 1. Annual Evaluatin by cardilgist knwledgeable in cngenital heart disease including echcardigram. Yes if: At least 3 mnths after surgery r at least 4 weeks after device clsure; asymptmatic and clearance by cardilgist knwledgeable in adult cngenital heart disease. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease every 2 years. Page 231 f 260

ATRIAL SEPTAL DEFECTS (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 125 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Atrial Septal Defect (ASD): Ostium Primum Small ASD = favrable prgnsis. Mderate t large ASD = unfavrable prgnsis Yes, if: Asymptmatic. N if: Symptms f dyspnea, palpitatins r a paradxical emblus; Ech-Dppler demnstrates pulmnary artery pressure > 50% systemic; Ech-Dppler demnstrates right-t-left shunt; Pulmnary t systemic flw rati greater than 1.5 t 1; Heart blck n an electrcardigram; Mre than mild mitral valve regurgitatin; Left ventricular utflw tract bstructin with a gradient >30 mm Hg. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease required including echcardigram. Yes if: Annual At least 3 mnths after Evaluatin by cardilgist surgical interventin if knwledgeable in adult nne f the abve cngenital heart disease. disqualifying criteria; N symptmatic arrhythmia and n significant residual shunt; Cleared by cardilgist knwledgeable in adult cngenital heart disease. Page 232 f 260

ATRIAL SEPTAL DEFECTS (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 126 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Sinus Vensus Atrial Septal Defect Usually assciated with anmalus pulmnary venus cnnectin. Prgnsis depends n size f atrial septal defect. Cmmnly assciated with sinus nde dysfunctin, particularly after surgery. Yes if: Small shunt and hemdynamically insignificant. N if: Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease. Symptms f dyspnea, palpitatins r a paradxical emblus; Ech-Dppler examinatin demnstrating pulmnary artery pressure greater than 50% systemic; Ech- Dppler examinatin demnstrating a right-tleft shunt; A pulmnary t systemic flw rati greater than 1.5 t 1; Heart blck r sinus nde dysfunctin n an electrcardigram. Yes if: At least 3 mnths after surgical interventin; Hemdynamics are favrable; Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease, including Hlter Mnitr. Cleared by cardilgist knwledgeable in adult cngenital heart disease. Page 233 f 260

BUNDLE BRANCH BLOCKS AND HEMIBLOCKS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 100 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Bundle Branch Blck Prgressin f disease in Yes if: Every 2 years. Axis Deviatin the cnductin system can lead t third degree Asymptmatic. (Depends n risk frm heart blck with ttal lss underlying heart disease.) f electrical cnnectin between the atria and Yes, if treated fr Annual ventricles causing symptmatic disease (see syncpe r sudden death. pacemaker); N disqualifying heart disease; Cleared by cardilgist. N, if symptmatic. Page 234 f 260

CARDIOMYOPATHIES AND CONGESTIVE HEART FAILURE (CHF) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 82 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Hypertrphic Cardimypathy Idipathic Dilated Cardimypathy and Cngestive Heart Failure N N, if symptmatic CHF. N if: Asymptmatic; Ventricular arrhythmias present; and LVEF <50%. N if: Asymptmatic; N ventricular arrhythmias; LVEF < 40%. Yes if: Asymptmatic; N ventricular arrhythmias; and LVEF 40% t 50%. Annual Requires annual cardilgy evaluatin including Echcardigraphy and Hlter mnitring. Restrictive cardimypathy N Page 235 f 260

COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 36 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Pst Mycardial Infarctin Risk f recurrent majr (MI) cardiac event highest within the first mnths pst-mi; Drivers in a rehabilitatin prgram can receive cmprehensive secndary preventin therapy. N if: Recurrent angina symptms; Pst-MI ejectin fractin <40% (by echcardigram r ventriculgram); Abnrmal ETT demnstrated prir t planned wrk return; Ischemic changes n rest ECG; Pr tlerance t current cardivascular medicatins. Yes if: At least 2 mnths pst- MI; Cleared by cardilgist; N angina; Pst-MI ejectin fractin >40% (by echcardigram r ventriculgram); Tlerance t current cardivascular medicatins. Annual Biennial ETT at minimum (If test psitive r incnclusive, imaging stress test may be indicated); Cardilgist examinatin recmmended. Angina Pectris Lwer end f spectrum amng CHD patients fr risk f adverse clinical utcmes. Cnditin usually implies at least ne crnary artery has hemdynamically significant narrwing. Yes, if asymptmatic. Annual N if: Biennial ETT at minimum Rest angina r change in (If test psitive r angina incnclusive, imaging pattern within 3 mnths f stress test may be examinatin; indicated). Abnrmal ETT; Cardilgist examinatin Ischemic changes n rest recmmended. ECG; Intlerance t cardivascular therapy. Page 236 f 260

COMMERCIAL DRIVERS WITH KNOWN CORONARY HEART DISEASE (CHD) (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 37 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Pst Percutaneus Crnary Interventin (PCI) Rapid recvery fr elective PCIs fr stable angina. Delayed re-stensis is the majr PCI limitatin and requires intensive secndary preventin. Yes if: At least 1 week after prcedure; Apprval by cardilgist; Tlerance t medicatins. ETT 3 t 6 mnths after PCI. N if: Annual Recmmend Cardilgist examinatin. Biennial ETT at minimum (If test psitive r incnclusive, imaging stress test may be indicated). Incmplete healing r cmplicatin at vascular access site; Rest angina; Ischemic ECG changes. Pst Crnary Artery Delay in return t wrk t Yes if: Annual Bypass Surgery (CABG) allw sternal incisin healing. Because f increasing risk f graft clsure ver time, ETT is btained. At least 3 mnths after CABG; LVEF > 40% pst CABG; Apprval by cardilgist; Asymptmatic; and tlerance t medicatins. After 5 years: Annual ETT. Imaging stress test may be indicated. Page 237 f 260

COMMERCIAL DRIVERS WITHOUT KNOWN CORONARY HEART DISEASE (CHD) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 35 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Asymptmatic, healthy Lw CHD event risk. Assess fr clinically apparent risk factrs. Use, when pssible, Framingham risk scre mdel t predict 10-year CHD event risk; Increasing age is a surrgate marker fr increasing athersclertic plaque burden. Yes, if asymptmatic. Rarely disqualifying alne. Biennial Asymptmatic, high risk Sub-clinical crnary Yes, if asymptmatic. Annual persn (as designated by athersclersis is a CHD risk-equivalent cncern. N if: cnditin)* Abnrmal ETT;** High-risk status requires Ischemic changes n Asymptmatic, high risk clse physician fllw-up ECG; persn > 45 years with and aggressive Functinal incapacitatin multiple risk factrs fr cmprehensive risk factr by ne f cnditins. CHD management. *CHD risk equivalent is defined as presence f diabetes mellitus, peripheral vascular disease, r Framingham risk scre predicting a 20% CHD event risk ver the next 10 years. ** Abnrmal Exercise Tlerance Test (ETT) is defined by an inability t exceed 6 METS (beynd cmpletin f Stage II, r 6 minutes) n a standard Bruce prtcl r the presence f ischemic symptms and/r signs (e.g., characteristic angina pain r 1 mm ST depressin r elevatin in 2 r mre leads), inapprpriate SBP and/r heart rate respnses (e.g., inability in the maximal heart rate t meet r exceed 85% f age-predicted maximal heart rate), r ventricular dysrhythmia. Ischemic ECG changes are defined by the presence f new 1 mm ST-segment elevatin r depressin and/r marked T wave abnrmality. Page 238 f 260

CONGENITAL HEART DISEASE 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 128 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Patent Ductus Arterisus Small = favrable. Yes, if small shunt. Annual (PDA) Mderate t large = unfavrable. N if: Symptms f dyspnea r palpitatins; Pulmnary hypertensin; Right t left shunt; Prgressive LV enlargement r decreased systlic functin. Yes if: At least 3 mnths after surgery r 1 mnth after device clsure; Nne f abve disqualifying criteria; Cleared by cardilgist knwledgeable in adult cngenital heart disease. Annual Shuld have evaluatin by cardilgist knwledgeable in adult cngenital heart disease. Carctatin f the Arta Mild = favrable. Yes if: Mild and unperated; BP cntrlled; and N assciated disqualifying disease. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease recmmended. Mderate r severe = unfavrable prgnsis. N Carctatin f the Arta Unfavrable prgnsis Yes, if Annual after interventin with persistent risk f perfect repair (see text p. Evaluatin by cardilgist cardivascular events. 115 and 116). knwledgeable in adult cngenital heart disease required. Page 239 f 260

CONGENITAL HEART DISEASE (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 129 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Pulmnary Valve Stensis (PS) Mild and mderate = favrable. Yes, if mild r mderate. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease. Severe PS may be unfavrable, assciated with arrhythmias and rarely sudden death. N if Symptms f dyspnea, palpitatins r syncpe; Pulmnary valve peak gradient >50 mm Hg with nrmal utput; RV pressuve >50% systemic pressure; >mile RVH; >mild RV dysfunctin; >mderate pulmnary valve regurgitatin; r main pulmnary artery >5cm. Yes if: 3 mnths after surgical valvtmy r 1 mnth after balln valvulplasty; Nne f abve disqualifying criteria; Cleared by cardilgist knwledgeable in adult cngenital heart disease. Annual Recmmend evaluatin by cardilgist knwledgeable in adult cngenital heart disease. Other causes f right Duble chambered right Yes if: Annual ventricular utflw ventricle. Hemdynamic data and Recmmend evaluatin bstructin in persns Infundibular pulmnary criteria similar t by cardilgist with cngenital heart stensis. individuals with islated knwledgeable in adult disease. Supravalvar pulmnary stensis. Pulmnary artery stensis. pulmnary valve stensis wh are eligible fr certificatin. cngenital heart disease. Page 240 f 260

CONGENITAL HEART DISEASE (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 130 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Yes if: Annual Ebstein anmaly Mild = favrable. Mild; Asymtmatic; Evaluatin by cardilgist N intracardiac lesins; knwledgeable in adult N shunt; cngenital heart disease. N symptmatic arrhythmia r accessry cnductin; Only mild cardiac enlargement; Only mild RV dysfunctin. Mderate and severe variants = unfavrable. N if: (see text, p. 117) Yes if: At least 3 mnths pstsurgical interventin; Nne f abve disqualifying features. Annual Echcardigram and evaluatin by cardilgist knwledgeable in adult cngenital heart disease required. Tetralgy f Fallt Unfavrable in the unrepaired state. N, if uncrrected. Repaired = variable prgnsis. Yes if: Excellent result btained frm surgery; Asymptmatic; N significant pulmnary r tricuspid valve regurgitatin; N pulmnary stensis; N histry f arrhythmias; N residual shunt. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease required, including EKG, 24 hur Hlter Mnitr, exercise testing, Dppler Echcardigram. Page 241 f 260

CONGENITAL HEART DISEASE (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 131 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Transpsitin f the Great Unfavrable if Vessels uncrrectable. N Atrial switch repair (Mustard r Senning prcedures). Unfavrable lng-term prgnsis. N After Rastelli repair. Yes if: Asymptmatic and excellent result btained frm surgery (see text). N if: (see text p. 119). Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease. After arterial switch repair, prgnsis appears favrable. N (Data currently nt sufficient t supprt qualificatin in this grup). Page 242 f 260

CONGENITAL HEART DISEASE (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 132 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Cngenitally crrected transpsitin 95% have assciated intracardiac lesins. Cnductin system is inherently abnrmal. Yes if: Nne f belw disqualifying criteria. Annual Required annual evaluatin by cardilgist knwledgeable in adult cngenital heart disease, includes echcardigraphy and 24 hur Hlter Mnitr. N if: Symptms f dyspnea, palpitatins, syncpe r paradxical emblus; Intracardiac lesin such as VSD; >mderate pulmnary stensis with a pulmnary ventricular pressure >50% systemic; >mild RV r LV enlargement r dysfunctin; Mderate r greater tricuspid valve (systemic atriventricular valve) regurgitatin; Histry f atrial r ventricular arrhythmia; ECG with heart blck; r Right-tleft shunt r significant residual left-t-right shunt. Yes if: At least 3 mnths after surgery; Nne f abve disqualifying criteria; Prsthetic valve - must meet requirements fr that valve; Cleared by cardilgist knwledgeable in adult cngenital heart disease. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease. Page 243 f 260

HEART TRANSPLANTATION 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 154 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Heart Transplantatin Special attentin t: Accelerated athersclersis, transplant rejectin, general health. Yes if: At least 1 year psttransplant; asymptmatic; stable n medicatins; n rejectin; Cnsent frm cardilgist t drive cmmercially. Biannual Clearance by cardilgist required. Page 244 f 260

HYPERTENSION 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 55 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Essential Hypertensin Evaluate fr ther clinical CVD including TOD ; Presence f TOD, CVD r diabetes may affect therapy selected. Yes, if asymptmatic. Rarely disqualifying alne. Stage 1 Usually asymptmatic; Yes Annual (140-159/90-99 mm Hg) Lw risk fr near-term incapacitating event. Rarely disqualifying alne. BP <140/90 at annual exam; If nt, but <160/100, certificatin extended ne time fr 3 mnths. Stage 2 Lw risk fr incapacitating Yes (160-179/100-109 mm event; risk increased in One time certificatin fr Hg) presence f TOD; 3 mnths. Indicatin fr pharmaclgic therapy. Yes, at recheck if: Annual BP <140/90mmHg Certify BP <140/90. fr 1 year frm date f initial exam. Stage 3 High risk fr acute N (>180/110 mm Hg hypertensin-related Immediately disqualifying; event. Yes, at recheck if: Every 6 mnths; BP <140/90 mm Hg; BP <140/90. Treatment is well tlerated. Certify fr 6 mnths frm date f initial exam. Secndary Hypertensin Evaluatin warranted if persistently hypertensive n maximal r nearmaximal dses f 2-3 pharmaclgic agents; May be amenable t surgical/specific therapy. Based n abve stages. Yes if: Stage 1 r nnhypertensive. At least 3 mnths after surgical crrectin. Annual BP <140/90 TOD Target Organ Damage Heart Failure, Strke r Transient Ischemic Attack, Peripheral Artery Disease, Retinpathy, Left Ventricular Hypertrphy, Nephrpathy. Examiner may disqualify a driver if TOD significantly impairs driver s wrk capacity. Driver shuld have n excess sedatin r rthstatic change in BP. Page 245 f 260

IMPLANTABLE DEFIBRILLATORS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 104 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Primary preventin Patient has high risk fr death and sudden incapacitatin. N Secndary preventin Patient demnstrated t have high risk fr death and sudden incapacitatin. N Page 246 f 260

MITRAL REGURGITATION 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 77 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Mild Mitral Regurgitatin Yes if: Asymptmatic; Nrmal LV size and functin;* Nrmal PAP. Annual Annual ech nt necessary. Mderate Mitral Yes if: Annual Regurgitatin Asymptmatic; Nrmal LV size and functin; * Nrmal PAP. Annual Echcardigram. Severe Mitral Regurgitatin Yes, if asymptmatic. Yes if: At least 3 mnths pstsurgery. Asymptmatic; cleared by cardilgist. Annual Echcardigram every 6-12 mnths. Exercise testing may be helpful t assess symptms. Annual N if: Symptmatic; Inability t achieve > 6 METS n Bruce prtcl; Ruptured chrdae r flail leaflet; Atrial fibrillatin; LV dysfunctin;* Thrmbemblism; Pulmnary artery pressure 50% f systlic arterial pressure; EF = Ejectin fractin; LVESD = Left ventricular end-systlic dimensin LVEDD = Left ventricular end-diastlic dimensin; PAP = Pulmnary artery pressure *Measures include: LVEF <60%; LVESD 45mm; LVEDD 70mm Page 247 f 260

MITRAL STENOSIS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 76 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL *Mild Mitral Stensis In the presence f Yes, if asymptmatic. Annual MVA >1.6 cm 2 symptms cnsistent with mderate t severe mitral stensis but a calculated valve area suggesting mild mitral stensis, the severity f the stensis shuld be reassessed and an alternative explanatin fr symptms shuld be cnsidered. Mderate Mitral Stensis MVA 1.0 t 1.6 cm 2 Severe Mitral Stensis MVA < 1.0 cm 2 Yes, if asymptmatic. N if: NYHA Class II r higher; Atrial fibrillatin; Pulmnary artery pressure >50% f systemic pressure; Inability t exercise fr >6 Mets n Bruce prtcl (Stage II). Annual Yes if: Annual At least 4 weeks pst Annual evaluatin by a percutaneus balln cardilgist. mitral valvtmy; r At least 3 mnths pst surgical cmmissurtmy; Clearance by cardilgist. MVA = mitral valve area *See text p.61 fr additinal echcardigram criteria. Page 248 f 260

PACEMAKERS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 101 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Sinus nde dysfunctin Variable lng term prgnsis depending n underlying disease, but cerebral hypperfusin crrected by supprt f heart rate by pacemaker. N Yes if: 1 mnth after pacemaker implantatin; and dcumented crrect functin by pacemaker center. Underlying disease is nt disqualifying. Annual Dcumented pacemaker checks. Atriventricular (AV) blck Variable lng term prgnsis depending n underlying disease, but cerebral hypperfusin crrected by supprt f heart rate by pacemaker. N Yes if: 1 mnth after pacemaker implantatin and dcumented crrect functin by pacemaker center; Underlying disease is nt disqualifying. Annual Dcumented pacemaker checks. Page 249 f 260

PACEMAKERS (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 102 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Neurcardigenic Excellent lng-term N, with symptms. Syncpe survival prgnsis but there is risk fr syncpe Yes if: that may be due t 3 mnths* after cardiinhibitry (slwing pacemaker implantatin; heart rate) r Dcumented crrect vasdepressr (drp in functin by pacemaker bld pressure) center; Absence f cmpnents, r bth. symptm recurrence. Pacemaker will affect nly cardiinhibitry cmpnent, but will lessen effect f vasdepressr cmpnent. Annual Dcumented pacemaker checks; Absence f symptm recurrence *Three mnths recmmended due t pssible vasdepressr cmpnent f syndrme nt necessarily treated by pacing. Page 250 f 260

PACEMAKERS (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 103 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Hypersensitive cartid sinus with syncpe Excellent lng-term survival prgnsis but there is risk fr syncpe that may be due t cardiinhibitry (slwing heart rate) r vasdepressr (drp in bld pressure) cmpnents, r bth. Pacemaker will affect nly cardiinhibitry cmpnent, but will lessen effect f vasdepressr cmpnent. N, with symptms. Yes if: 3 mnths* after pacemaker implantatin; and dcumented crrect functin by pacemaker center; Absence f symptm recurrence. Annual Dcumented regular pacemaker checks; and Absence f symptm recurrence *Three mnths recmmended due t pssible vasdepressr cmpnent f syndrme nt necessarily treated by pacing. Page 251 f 260

PERIPHERAL VASCULAR DISEASE 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 146 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Peripheral Vascular Disease (PVD) Evaluate fr assciated cardivascular diseases. Yes, if n ther disqualifying cardivascular cnditin. Annual Intermittent Claudicatin Mst cmmn presenting Yes if: manifestatin f cclusive At least 3 mnths arterial disease. after surgery; Relief f symptms; N ther disqualifying cardivascular disease. Annual Rest pain. N, if symptms. Yes if: At least 3 mnths after surgery; Relief f symptms and signs; N ther disqualifying cardivascular disease. Annual Page 252 f 260

SUPRAVENTRICULAR TACHYCARDIAS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 96 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Atrial Fibrillatin Lne Atrial Fibrillatin Gd prgnsis and lw risk fr strke. Yes Annual Atrial fibrillatin as cause f r a risk fr strke Risk fr strke decreased by anticagulatin. Yes if: Anticagulated adequately fr at least 1 mnth; Anticagulatin mnitred by at least mnthly INR; Rate/rhythm cntrl deemed adequate (Recmmend assessment by cardilgist). Annual Atrial fibrillatin fllwing thracic surgery Gd prgnsis and duratin usually limited. In atrial fibrillatin at time Annual f return t wrk; Yes if: Anticagulated adequately fr at least 1 mnth; Anticagulatin mnitred by at least mnthly INR; Rate/rhythm cntrl deemed adequate (Recmmend assessment by cardilgist). Page 253 f 260

SUPRAVENTRICULAR TACHYCARDIAS (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 97 DIAGNOSIS PHYSIOLOGY/ FUNCTIONAL CERTIFICATION RE-CERTIFICATION Atrial flutter Same as fr atrial fibrillatin. Same as fr atrial fibrillatin. Yes if: Isthmus ablatin perfrmed and at least 1 mnth after prcedure; Arrhythmia successfully treated; Cleared by electrphysilgist. Same as fr atrial fibrillatin. Annual Multifcal Atrial Tachycardia Often assciated with cmrbidities, such as lung disease, that may impair prgnsis. Yes if: Asymptmatic; Unless assciated cnditin is disqualifying. Annual N, if symptmatic. Yes if: Annual. Symptms cntrlled and secndary cause is nt exclusinary. Atriventricular Ndal Reentrant Tachycardia (AVNRT) Atriventricular Reentrant Tachycardia (AVRT) and Wlff-Parkinsn-White (WPW) Syndrme Atrial Tachycardia Junctinal Tachycardia Prgnsis generally excellent, but may rarely have syncpe r symptms f cerebral hypperfusin. Fr thse with WPW, preexcitatin presents risk fr death r syncpe if atrial fibrillatin develps. N if: Symptmatic; r WPW with atrial fibrillatin. Yes if: Asymptmatic; Treated and asymptmatic fr at least 1 mnth and assessed and cleared by expert in cardiac arrhythmias. Annual Recmmend cnsultatin with cardilgist Page 254 f 260

VALVE REPLACEMENT 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 80 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Mechanical Valves Yes if: At least 3 mnths pstp; Asymptmatic; Cleared by cardilgist. Annual Recmmend evaluatin by cardilgist.* N if: Symptmatic; LV dysfunctin-ef < 40%; Thrmbemblic cmplicatin pst prcedure; Pulmnary hypertensin; Unable t maintain adequate anticagulatin (based n mnthly INR checks). Prsthetic valve N dysfunctin. Yes if: Surgically crrected; At least 3 mnths pst-p; Asymptmatic; Cleared by cardilgist. * Rle f annual echcardigraphy in stable patients is cntrversial. Annual Recmmend evaluatin by cardilgist.* Page 255 f 260

VALVE REPLACEMENT (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 81 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Atrial fibrillatin. Yes if: Anticagulated adequately fr at least 1 mnth and mnitred by at least mnthly INR, rate/rhythm cntrl adequate; Cleared by cardilgist. Annual Bilgic Prstheses Anticagulant therapy nt necessary in patients in sinus rhythm (after initial 3 m0nths), in absence f prir embli r hypercagulable state. Yes if: At least 3 mnths pstp; Asymptmatic; Nne f abve disqualifying criteria fr mechanical valves; Cleared by cardilgist. Annual Recmmend evaluatin by cardilgist.* Page 256 f 260

VENOUS DISEASE 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 147 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Acute Deep Vein Thrmbsis (DVT) Superficial Phlebitis Pulmnary Emblus N, if symptms. Yes if: N residual acute deep venus thrmbsis; If n Cumadin: Regulated fr at least 1 mnth; INR mnitred at least mnthly. Yes if: DVT ruled ut; N ther disqualifying cardivascular disease. N, if symptms. Annual Biennial Yes if: N pulmnary emblism fr at least 3 mnths; On apprpriate lng-term treatment. If n Cumadin: Regulated fr at least 1 mnth; INR mnitred at least mnthly; N ther disqualifying cardivascular disease. Annual Chrnic Thrmbtic Venus Disease Yes, if n symptms. Biennial Varicse veins Yes, if n cmplicatins. Biennial Cumadin Use f INR required. Yes if: Stabilized fr 1 mnth; INR mnitred at least mnthly. Annual Page 257 f 260

VENTRICULAR ARRHYTHMIAS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 98 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Crnary Heart Disease (CHD) Sustained VT: Pr prgnsis and high risk. NSVT, LVEF < 0.40: Unfavrable prgnsis. NSVT, LVEF >0.40: Generally cnsidered t have gd prgnsis. N N N, if symptmatic. Yes if: Asymptmatic. At least 1 mnth after drug r ther therapy is successful; Cleared by cardilgist. Annual Cardilgy examinatin required. Dilated Cardimypathy NSVT (LVEF < 0.40). Sustained VT, any LVEF. Syncpe/near syncpe, any LVEF: High risk. N N N Hypertrphic Cardimypathy Variable but uncertain prgnsis. N Page 258 f 260

VENTRICULAR ARRHYTHMIAS (Cntinued) 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 99 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Right Ventricular Outflw VT Favrable prgnsis and lw risk fr syncpe. N, if symptmatic. Yes, if asymptmatic. Yes if: At least 1 mnth after drug r ther therapy successful; Asymptmatic; Cleared by electrphysilgist. Annual Recmmend evaluatin by cardilgist. Annual Evaluatin by cardilgist required. Idipathic Left Ventricular VT Favrable prgnsis and lw risk fr syncpe. N, if symptmatic Yes, if asymptmatic. Yes if: At least 1 mnth after successful drug therapy r ablatin; Cleared by electrphysilgist. Annual Recmmend evaluatin by cardilgist. Annual Evaluatin by cardilgist required. Lng QT Interval Syndrme Brugada Syndrme High risk fr ventricular arrhythmic death. High risk fr ventricular arrhythmic death. N N Page 259 f 260

VENTRICULAR SEPTAL DEFECTS 2002 Cardivascular Cnference Reprt Recmmendatin Tables, Page 127 PHYSIOLOGY/ DIAGNOSIS CERTIFICATION RE-CERTIFICATION FUNCTIONAL Ventricular Septal Defect Small = favrable. Yes, if small shunt. Annual Evaluatin by cardilgist knwledgeable in adult cngenital heart disease recmmended. Mderate t large VSD has effect n pulmnary pressure and ventricular size and functin. N if: Mderate t large VSD; Symptms f dyspnea, palpitatins r syncpe; Pulmnary artery hypertensin; Right-t-left shunt, left ventricular enlargement r reduced functin; Pulmnary t systemic flw rati greater than 1.5 t 1. Yes if: Annual At least 3 mnths after Evaluatin by cardilgist surgery; knwledgeable in adult Nne f abve cngenital heart disease, disqualifying criteria; including 24 hur Hlter N serius dysrhythmia Mnitring. n 24 hur Hlter Mnitring; QRS interval <120 ms; (If right ventricle cnductin delay >120 ms n ECG, can be certified if invasive HIS bundle studies shw n infra-his blck r ther serius electrphysilgic disrder); Cleared by cardilgist knwledgeable in adult cngenital heart disease. Page 260 f 260