Commercial Driver Medical Examiner Training: Improving … Driver ME... · person training for health care professionals who perform physical examinations for Commercial Motor Vehicle

Commercial Driver Medical Examiner Training: Improving Transportation Safety through Education and Certification

2015

© Mayo Foundation for Medical Education and Research

ii

Terms of Use

Disclaimer This information is made available by Mayo Clinic for educational purposes only. The material is not medical advice and is not intended to represent the only, or best, methods or procedures appropriate for the medical situation discussed; rather is intended to present an approach, view, statement or opinion of the presenters that may be helpful or of interest to other practitioners. Procedures, products or instrumentation systems used, discussed and/or demonstrated may be experimental and may not have yet received FDA approval. All rights reserved. You may not copy, distribute, broadcast, sell, edit create new works from, or publically perform or display course materials without the permission of Mayo Clinic.

No Warranties You understand and agree that the content or information contained or provided herein is provided on an "as is" basis. Mayo Clinic College of Medicine does not make any express or implied warranties, representations or endorsements whatsoever (including without limitation warranties of title or non-infringement, or the implied warranties of merchantability or fitness for a particular purpose) with regard to the information, content or service provided herein. In addition, Mayo Clinic College of Medicine does not guarantee this product will be free from technological difficulties and you understand that you are responsible for implementing sufficient procedures and checkpoints to satisfy your particular system requirements for accuracy of data input and output.

Limitation of Liability The use of this service is entirely at your own risk, and in no event shall Mayo Clinic be liable for any direct, indirect, incidental, consequential, special, exemplary, punitive, or any other monetary or other damages, fees, fines, penalties, or liabilities arising out of or relating in any way to content, information, or service provided herein.

User Agreements By accepting these materials, you agree that you will not:

1. Transmit any communications or content of any type that may infringe or violate any rights of any party.

2. Use this course material for any purpose in violation of local, state, national or international laws. 3. Use this course material as a means to distribute advertising or other unsolicited material to any

third party. 4. Use this course material in connection with any material that is unlawful, obscene, defamatory,

threatening, harassing, abusive, slanderous, hateful or embarrassing to any other person or entity.

iii

Copyright and Trademark Information The marks "Mayo," "Mayo Clinic," and the triple-shield Mayo logo are trademarks and/or service marks of Mayo Foundation for Medical Education and Research. The content and designs are protected by U.S. and international copyright laws. You may not copy, reproduce, republish, upload, post, display, transmit, or frame any of these materials without prior written consent from the copyright owners, except that you may view, display and print a single copy of these materials on a single computer for personal, noncommercial use only, so long as (1) you do not alter or modify the materials in any way; (2) you include all applicable notices and disclaimers (including copyright notices), and (3) you do not use the materials in a way that suggests an association with Mayo Clinic or an affiliated Mayo entity. You understand and agree that title to these materials shall not pass to you or any other user.

Disputes By accepting these materials, you agree the rights and obligations herein shall be governed by the laws of the state of Minnesota, except that no state of Minnesota conflicts-of-law or choice-of-laws provisions shall apply; and the exclusive fora for any actions are the State District Court sitting in Olmsted County, Minnesota, or the United States Court for the District of Minnesota. You unconditionally agree to be personally subject to the jurisdiction of such court. Copyright ©2001-2015 Mayo Foundation for Medical Education and Research. All rights reserved.

iv

Table of Contents CME Activity Description ............................................................................................................................ v

CME Activity Objectives .............................................................................................................................. v

Intended Audience ........................................................................................................................................ v

Continuing Education Credit ....................................................................................................................... vi

CME Record of Attendance ......................................................................................................................... vi

CME Activity Evaluation ............................................................................................................................ vi

Syllabus and Internet Access ...................................................................................................................... vii

Recording Device Policy ............................................................................................................................ vii

Electronic Devices ...................................................................................................................................... vii

Faculty ....................................................................................................................................................... viii

Faculty and Provider Disclosure Summary ................................................................................................. ix

Program Schedule ......................................................................................................................................... x

Presentations ................................................................................ See Program Schedule for Page Numbers

Resources .................................................................................................................................................. 139 Form 649-F ............................................................................................................................................... 197

Certificate for Drivers ............................................................................................................................... 205

v

CME Activity Description

Committed to improving transportation safety through education and certification, Mayo Clinic offers in-person training for health care professionals who perform physical examinations for Commercial Motor Vehicle (CMV) drivers. Effective May 21, 2014, all health care professionals who perform physical examinations and issue medical certificates for CMV drivers will be required to complete accredited certification training and pass an examination. This interactive course will provide the essential core administrative and clinical knowledge necessary to complete the required examination mandated by the Federal Motor Carrier Safety Administration (FMCSA). This course will review certain subspecialty diseases and conditions encountered while performing CMV examinations, utilizing a case-based interactive approach focused on efficiently addressing complex clinical issues. Participants will have the opportunity to experience the physical demands associated with operating a large commercial vehicle with a semi-trailer at the course site. The training includes the following core competencies:

The examiner’s role in enhancing public safety Diagnostic approaches in assessing medical fitness of the commercial driver Navigating clinical and administrative issues commonly encountered in driver medical

certification Understanding and effectively managing the complexity of the physical requirements and stresses

involved in operating commercial vehicles Strategies for prevention and health promotion for CMV drivers

Content will focus on the core curriculum required by the FMCSA. Following completion of this training, participants will receive the certification required to take the NRCME examination.

CME Activity Objectives Upon conclusion of this program, participants should be able to:

Describe the specific physical and mental demands associated with operating a commercial motor vehicle (CMV).

Understand the responsibilities of a CMV driver. Recognize potentially disqualifying diseases, medications, or health conditions in the examination

process, and provide drivers with parameters for safely proceeding with work duties. Document the requirements for the medical history and physical examination of a CMV operator. Develop strategies for efficiently conducting forensic evaluations, including addressing difficult

issues in the certification process. Discuss a variety of strategies for promoting improved health and wellness in this cohort of

individuals. Understand step-by-step process of registering for FMCSA exam and NRCME registry.

Attendance at this Mayo Clinic activity does not indicate nor guarantee competence or proficiency in the performance of any procedures which may be discussed or taught in this activity.

Intended Audience

This program is designed for health care professionals who will be performing DOT examinations, or who have an interest in promoting wellness in the population of professional drivers.

vi

Continuing Education Credit

Mayo Clinic College of Medicine is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. Mayo Clinic College of Medicine designates this live activity for a maximum of 7.5 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. This Live activity, Commercial Driver Medical Examiner Training: Improving Transportation Safety through Education and Certification, from 03/28/2015 - 11/07/2015, has been reviewed and is acceptable for up to 7.50 Prescribed credit(s) by the American Academy of Family Physicians. Physicians should claim only the credit commensurate with the extent of their participation in the activity This activity was approved by the American Board of Preventive Medicine for Maintenance of Certification (MOC) credit for a maximum of 7.5 LLSA/MOC credits. This physician board credit can only be granted following completion of the pre-test, course activity, and post-test. ABPM diplomate number will be required for successful upload to ABPM.

CME Record of Attendance

A Record of Attendance is provided to you during on-site registration. The Record of Attendance allows attendees to calculate their own credits of participation in the educational activity. The total number of credits participants can earn per day is noted on the Record of Attendance. Below each day is a line to record the actual number of credits during which you participated in the educational activity. It is recommended that you record your actual credits daily as you proceed through the CME activity. Upon conclusion of the CME activity, please total the number of credits you have recorded on the top half of the form, sign it, and return it with your evaluation to the registration desk. The bottom half of the form represents your Record of Attendance, which you must retain for your records. Please make sure the number of credits claimed in both sections coincide. No other documentation is provided to you after this CME activity. The Record of Attendance has replaced the certificate. The Record of Attendance can be used for requesting credits in accordance with state licensing boards, specialty societies, or other professional associations.

CME Activity Evaluation

The overall CME activity evaluation will be emailed following the activity to the email address that was provided when you registered. The CME activity evaluation is brief and will only take a few minutes to complete. Faculty evaluation forms were offered to a sampling of the registrants. Completed faculty evaluation forms should be returned to the registration desk at the conclusion of the CME activity. If you wish to participate in evaluating the faculty, please stop at the registration desk to inquire if extra evaluation forms are available.

vii

Your feedback is very important to us and will be used for planning future programs, as well as identifying faculty strengths and opportunity for growth.

Syllabus and Internet Access

An electronic syllabus will be provided to all attendees. Participants are invited to bring their laptops to the meeting room(s). Due to copyright issues or revisions, some slides may be shown during a presentation, but not provided within the syllabus.

Recording Device Policy

No recording devices, audio or visual, may be used during Mayo Clinic College of Medicine CPD activities. Duplication, distribution, or excerpting of this program, without the express written permission of Mayo Clinic, is strictly prohibited. All of the proceedings of this program, including the presentation of scientific papers, are intended for limited publication only, and all property rights in the material presented, including common-law copyright, are expressly reserved by the Faculty and/or Mayo Clinic. No statement of presentation made is to be regarded as dedicated to the public domain. Any sound reproduction, transcript or other use of the material presented at this CME activity without the permission of Mayo Clinic is prohibited to the full extent of common-law copyright in such material.

Electronic Devices

Please turn all electronic devices (cellular telephones, pagers, etc.) to silent mode. As a courtesy to the presenters and other participants, phone calls should be taken outside of the general session.

viii

Faculty Course Director Clayton T. Cowl, M.D., M.S. Mayo Clinic Associate Professor of Medicine Division of Preventive, Occupational, and Aerospace Medicine Division of Pulmonary & Critical Care Medicine

Mayo Clinic

Cindy M. Boyum, R.N., C.N.P. Department of Family Medicine Steven M. Bruce, M.D. Instructor in Family Medicine Department of Family Medicine William G. Buchta, M.D. Instructor in Preventive Medicine Division of Preventive, Occupational, and Aerospace Medicine Darryl S. Chutka, M.D. Associate Professor of Medicine Executive Health Program Associate Dean, Mayo School of Continuous Professional Development Sarah J. Crane, M.D. Assistant Professor of Medicine Division of Primary Care Internal Medicine Philip T. Hagen, M.D. Assistant Professor of Medicine Division of Preventive, Occupational, and Aerospace Medicine Terry W. Kuhlwein, M.D. Instructor of Family Medicine Occupational Medicine James M. Lance, D.O., M.P.H. Instructor of Family Medicine Occupational Medicine

Program Faculty

Debra K. McCauley, R.N., C.N.P. Department of Family Medicine Robin G. Molella, M.D. Instructor in Preventive Medicine Division of Preventive, Occupational, and Aerospace Medicine Richard D. Newcomb, M.D. Instructor in Preventive Medicine Division of Preventive, Occupational, and Aerospace Medicine Cheryl L. Pietila, R.N., C.N.P. Department of Family Medicine Mark W. Steffen, M.D. Division of Preventive, Occupational, and Aerospace Medicine Debra Thompson, R.N., F.N.P.-C., C.N.P. Mayo Clinic Health System – Mankato Department of Occupational Medicine Barbara J. Timm, R.N., C.N.P. Division of Preventive, Occupational, and Aerospace Medicine John M. Wilkinson, M.D. Assistant Professor of Medicine Department of Family Medicine

ix

Faculty, Planning Committee and Provider Disclosure Summary


As a provider accredited by ACCME, College of Medicine, Mayo Clinic (Mayo School of CPD) must ensure balance, independence, objectivity and scientific rigor in its educational activities. Course Director(s), Planning Committee Members, Faculty, and all others who are in a position to control the content of this educational activity are required to disclose all relevant financial relationships with any commercial interest related to the subject matter of the educational activity. Safeguards against commercial bias have been put in place. Faculty also will disclose any off label and/or investigational use of pharmaceuticals or instruments discussed in their presentation. Disclosure of these relevant financial relationships will be published in activity materials so those participants in the activity may formulate their own judgments regarding the presentation. Listed below are individuals with control of the content of this program who have disclosed… Relevant financial relationship(s) with industry:

Name Nature of Relationship Company None

No relevant financial relationship(s) with industry:

Name Cindy M. Boyum, R.N., C.N.P.

Steven M. Bruce, M.D.

William G. Buchta, M.D.

Darryl S. Chutka, M.D.

Clayton T. Cowl, M.D., M.S.

Sarah J. Crane, M.D.

Kathy Fuqua

Philip T. Hagen, M.D.

Terry W. Kuhlwein, M.D.

James M. Lance, D.O., M.P.H.

Debra K. McCauley, R.N., C.N.P.

Robin G. Molella, M.D.

Richard D. Newcomb, M.D.

Cheryl L. Pietila, R.N., C.N.P.

Mark W. Steffen, M.D.

Debra Thompson, R.N., F.N.P.-C, C.N.P.

Barbara J. Timm, R.N., C.N.P.

John M. Wilkinson, M.D.

References to off-label and/or investigational usage(s) of pharmaceuticals or instruments in their presentation:

Name Manufacturer/Provider Product/Device None

x

Program Schedule


2015 Courses

7:30 a.m. Registration and Refreshments

8:00 a.m. Session 1: The Examiner’s Role in Enhancing Public Safety (includes 15-minute break) ............................. 12

10:00 a.m. Session 2: Diagnostic Approaches in Assessing Medical Fitness of the Commercial Driver ......................... 38

12:00 p.m. Lunch – Boxed Lunch Provided

1:00 p.m. Session 3: Navigating Clinical Issues in Driver Medical Certification ............................................................. 70

2:30 p.m. Refreshment Break

2:45 p.m. Session 4: Making the Forensic Determination ................................................................................................ 112

4:00 p.m. Session 5: National Registry Signup & Exam Preparation .............................................................................. 125

5:00 p.m. Adjourn

The Examiner’s Role in Enhancing Public Safety Overview of FMCSA Initiatives and Programmatic Structure Epidemiologic Data on Commercial Motor Vehicle Highway Safety Form Completion and Documentation (including Laboratory and Office Based Diagnostic Testing Understanding Workplace Stressors in the Driving Environment Hands-on Primer on How a Truck Works (Parking Lot)

Diagnostic Approaches in Assessing Medical Fitness of the Commercial Driver

Strategies for Targeted History Taking and Efficient Physical Examinations Overview of Non-Discretionary Disqualifying Conditions Organ System Based Review of Commonly Encountered Medical Conditions

o Vision o Auditory Acuity o Diabetes Mellitus and Endocrine Disorders o Hypertension

Navigating Clinical Issues in Driver Medical Certification

Organ System Based Review of Commonly Encountered Medical Conditions (Cont.) o Cardiovascular o Respiratory (Including Sleep-Related Disordered Breathing) o Neurological o Substance Abuse and Medication Use

Making the Forensic Determination

The Role of Prevention and Counseling in Driver Cohorts Judging Recertification Intervals Interactive Review of Case Examples Review of Electronic Resources for Course

National Registry Signup & Exam Preparation

Specific Directions on Registry Signup & Exam Preparation How to Register for the FMCSA Medical Examiner Test Review of Electronic Resources from Course to Use in Practice

Let’s Roll!

Welcome to the Mayo Clinic course on Commercial Driver Medical Examiner Training! My colleagues and I have been working to provide every attendee a valuable experience packed full of useful kernels of clinical knowledge combined with the opportunity to learn more about trucks, the trucking industry, and the multiple stressors that affect the drivers who we examine. It is impossible to cover every topic of commercial motor vehicle examination training in a one-day course, and no educational platform can replace the clinical knowledge base and efficiencies learned through years of experience in performing these examinations on a regular basis. However, our desire is to deliver a very efficient platform for each of you to learn the essentials of completing these examinations, and to provide an “electronic toolbox” for your use over time as a reliable resource. This course will meet the key curriculum requirements outlined by the Federal Motor Carrier Safety Administration (FMCSA) and assist you in passing the examination required to become a valid provider in its National Registry of Certified Medical Examiners (NRCME). This includes coverage of administrative details involved in the oversight of examinations, information on how to correctly complete medical application forms, and clinical pearls in completing the physical examination and how to make a certification determination. This learning activity is not intended to be a primary tool for providers to learn how to perform a physical examination or how to master the basics of history-taking and diagnosis as it is assumed that participants are appropriately licensed to practice medicine or chiropractic care in their respective states or jurisdictions and will have already completed training in these areas.

This course will focus on skills required for participants to perform commercial driver medical examinations efficiently. But more importantly, our goal is for each of you to come away with an appreciation of what drivers face in their occupations, and recognize the lifestyle issues that lead to unacceptable levels of obesity, tobacco abuse, hypertension, diabetes, coronary artery disease, and sleep-related disordered breathing such as sleep apnea. Together, we as a medical profession can make important contributions to improving the health of the people who transport the very materials we all use on a daily basis and with whom we share the roads.

Thanks so much for trusting us here at Mayo Clinic with the opportunity to share this material, and I look forward to our continuing interactions in the future!

Clayton T. Cowl, MD, MS Course Director

©2014 MFMER | 3212718-1

Commercial Driver MedicalExaminer Training:

Improving Transportation Safety through

Education and Certification

Session 1 Live Course

©2014 MFMER | 3212718-2

The Examiner’s Role in Enhancing Public Safety

I am a current DOT Medical Examiner.

©2012 MFMER | 3212718-3

1 2

0%0%

1. Yes

2. No

I am which of the following types of health care providers…

©2012 MFMER | 3212718-4

1 2 3 4 5

0% 0% 0%0%0%

1. Medical Doctor

2. Osteopathic Physician

3. Chiropractor

4. Advanced Practice Nurse

5. Physician Assistant

My gender is:

©2012 MFMER | 3212718-5

1 2

0%0%

1. Male

2. Female

My main practice location is in…..

©2012 MFMER | 3212718-6

1 2 3 4 5 6

0% 0% 0%0%0%0%

1. Minnesota

2. Wisconsin

3. North Dakota

4. South Dakota

5. Iowa

6. Illinois

7. Other

©2014 MFMER | 3212718-7

What are the FMCSA core curriculum topics?

• Background, rationale, mission, and Medical Examiner’s role

FMCSAFederal Motor Carrier Safety Administration

• Commercial Motor Vehicle (CMV) driver’s responsibilities and work

©2014 MFMER | 3212718-8


• CMV driver identification and medical history• Obtaining, reviewing, and documenting • Prescription and over-the-counter medications

©2014 MFMER | 3212718-9


• Performing and documenting the Medical Examination

©2014 MFMER | 3212718-10


• Additional diagnostic tests or medical opinions, as needed • Performing, obtaining, and documenting diagnostic tests• Obtaining medical specialist/treating physician opinion

©2014 MFMER | 3212718-11


• Inform/educate CMV driver• Medications and/or non-disqualifying medical conditions needing

care

©2014 MFMER | 3212718-12


• Determining driver certification outcome (including period for which certification is valid)

• FMCSA reporting and documentation requirements

©2014 MFMER | 3212718-13

Federal Motor Carrier Safety Administration (FMCSA)

• Was created with the signing of the Motor Carrier Safety Improvement Act of 1999 by President Clinton

• The FMCSA evolved from the Federal Highway Administration

• Is one of several administrations and agencies housed under the Department of Transportation

• Headquarters in Washington DC

©2014 MFMER | 3212718-14

FMCSA

Mission:

“Focused on reducing crashes, injuries, and fatalities involving large trucks and buses.”

©2014 MFMER | 3212718-15

• Attempt to establish regulations that balance safety with industry efficiency using objective data

• Utilize a systems approach to target higher-risk motor carriers• Develops educational messages to carriers, commercial drivers and

the public• Partners with Federal, State, and local agencies, the motor carrier

industry, safety groups, and organized labor to target reduction of bus and truck-related crashes

©2014 MFMER | 3212718-16

Focused on Medical Guidelines and Standards

FMCSAOrganizational Framework

©2014 MFMER | 3212718-17

FMCSAOffice of Medical Programs• Oversees national medical certification process for CMV

drivers in interstate commerce

• Develops and reviews medical regulations, policies and procedures

• Responsible for the national registry of medical examiners program and a national driver medical reporting system

• Recruits, oversees and supports the Medical Review Board (MRB) as dictated by the Federal Advisory Committee Act as well as Medical Expert Panels (MEPs)

• Leads the medical exemption and certification programs

• Guides efforts to conduct medical research in the areas of CMV driver health and safety trends

©2014 MFMER | 3212718-18

FMCSAOffice of Analysis, Research & Technology

• Produces reports analyzing prevalence of fatalities and serious injuries, trends, and costs involving large truck and bus crashes

• Objective data collated by this office is used to direct efforts to minimize accidents and injuries, and to attenuate the severity of accidents when they do occur

• Involved in generating all economic and environmental data used for federal rulemaking

• Makes statistical data easily accessible to the public

The FMCSA continually reviews medical standards and guidelines

• Agency expert analyses of federal data and other relevant international, national, and state data

• Interagency, national, and international regulatory analyses

• Evidence reports

• Medical Expert Panels (MEPs)

• Medical Review Board (MRB) -- a committee established in accordance with the Federal Advisory Committee Act

©2014 MFMER | 3212718-19

Medical guidelines and MEP opinions

• Posted on the FMCSA website

• MRB meets 3-4 times per year on specific topics

• MRB independently reviews evidence reports and if a MEP was convened, also reviews MEP opinion. The MRB deliberates and proposes recommendations for consideration by FMCSA

• MRB proceedings and public meetings are also posted on an internet-based format

• New standards require a Notice of Proposed Rule Making and publication in the Federal Register

©2014 MFMER | 3212718-20

What organization is responsible for developing and maintaining the NRCME?

©2012 MFMER | 3212718-21

1 2 3 4

0% 0%0%0%

1. State DOT office

2. Office of the Assistant Administrator (Chief Safety Officer)

3. Office of Medical Programs

4. Office of Analysis, Research & Technology

All of the following statements are correct EXCEPT:

©2012 MFMER | 3212718-22

1 2 3 4

0% 0%0%0%

1. The Medical Expert Panel (MEP) provides opinions on specific medical conditions.

2. The Medical Review Board reviews and is required to implement MEP opinions.

3. Any new standard must complete a full public review process.

4. All MRB and MEP reports and actions are posted on the FMCSA web site.

Commercial Motor Vehicle Crashes• Occupants of lighter

vehicles often sustain much more severe injuries

• Injury severity is directly proportional to mass and its corresponding velocity changes

• Heavier vehicles such as large trucks and buses are many times the weight of smaller passenger vehicles

©2014 MFMER | 3212718-23

Large Truck Accident Prevalence is High

• In 2010 more than 500,000 Large Truck and Commercial Vehicles were involved in accidents

• More than 100,000 people sustained serious injuries, and more than 5000 people died in these crashes

• More than 20% more CMVs are expected to hit the roads by 2016*

∗data from the Insurance Institute for Highway Safety

©2014 MFMER | 3212718-24

Which of the following statements are true?

©2012 MFMER | 3212718-25

1 2 3 4

0% 0%0%0%

1. More than 100,000 people sustained injuries involving large trucks in 2010.

2. CSA stands for, “Compliance, Service and Action.”

3. In CMV accidents, almost twice as many deaths involved drivers of large trucks as compared to drivers of SUVs.

4. Because of new regulations, it is anticipated that 20% fewer commercial motor vehicles will be on the road by 2014.

©2014 MFMER | 3212718-26

Title 49“FMCSA, Department of Transportation”

Part 391Section 41

Subpart E“Physical Qualifications and

Examinations”

49 CFR 391.41

Code of Federal Regulations• These are legal regulations – not

guidelinesMedical Guidelines or Advisory Criteria

• Based upon expert review and considered best practice

• ME may or may not choose to use these recommendations, but reason for not following guidelines should be clearly explained in their documentation

The federal statute that outlines the physical requirements for a CMV driver is:

©2012 MFMER | 3212718-27

1 2 3 4

0% 0%0%0%

1. 49 CFR 391.45

2. FAR 61.53

3. 49 CFR 391.47

4. 49 CFR 391.41

©2014 MFMER | 3212718-28

Regulation Description

49 CFR 391.41

Describes the physical qualification requirements for drivers. The 13 standards are used to determine driver medical fitness for duty. Four of the standards: vision, hearing, epilepsy, and diabetes mellitus have objective disqualifiers that do not depend on medical examiner clinical interpretation. These standards are the "non-discretionary" standards. For the other nine "discretionary" standards, the medical examiner makes a clinical judgment in accordance with the physical qualification requirements for driver certification.

49 CFR 391.43 Describes the responsibilities of the medical examiner, including general instructions for performing the medical examination, a description of driver tasks and work environment, medical advisory criteria, the sample Medical Examination Report form, and the medical examiner's certificate.

49 CFR 391.45Identifies who must have the commercial motor vehicle (CMV) driver physical examination.

49 CFR 391.47Describes the process for conflict resolution when there is a disagreement between the primary care provider for the driver and the medical examiner for the motor carrier concerning driver qualifications.

49 CFR 391.49

Describes the Skill Performance Evaluation (SPE) Certification Program, which is an alternative physical qualification standard for the driver with a fixed musculoskeletal deficit of an extremity who cannot physically qualify to drive under §391.41(b)(1) or (b)(2). The driver must be otherwise qualified to drive a CMV and meet the provisions of the alternate standard. The first program to address fixed musculoskeletal deficits was created and administered by the Interstate Commerce Commission (ICC) in 1964 and was known as the Handicapped Driver Waiver Program.

49 CFR 391.62Describes limited exemptions for intra-city zone drivers.

49 CFR 391.64Describes grandfathering for certain drivers who participated in vision and diabetes waiver study programs. These drivers may be certified as long as they continue to meet the provisions outlined in 49 CFR 391.64 and continue to meet all other qualification standards.

49 CFR 390 Includes general information and definitions.

49 CFR 40 Includes regulations for medical review officers and substance abuse professionals (SAPs), including drug and alcohol testing procedures.

©2014 MFMER | 3212718-29

WhoMust be certified?

Literally millions of drivers require evaluation

• Estimated 6-9 million CMV drivers must comply with FMCSA physical standards

• The FMCSA estimates that there will need to be 3-5 million medical examinations each year

• Shortages of drivers are being realized

©2014 MFMER | 3212718-30

What is the typical driver profile?**

• Male

• >40 years of age

• Sedentary

• Overweight

• Tobacco abuse

• Poor eating habits

Medically:• Less healthy than the

average person• > 2 medical conditions• Prevalent cardiovascular

disease• Higher rates of sleep apnea

©2014 MFMER | 3212718-31

** from FMCSA data

©2014 MFMER | 3212718-32

WhatIs a commercial motor

vehicle?

Commercial Motor Vehicle• Any self-propelled or towed motor vehicle used on a highway in

interstate commerce to transport passengers or property when the vehicle:

• Has a gross vehicle weight rating or gross combination weight rating, of 4,536 kg (10,001 pounds) or more, whichever is greater; or

• Is designed or used to transport more than 8 passengers (including the driver) for compensation; or

• Is designed or used to transport more than 15 passengers, including the driver, and is not used to transport passengers for compensation; or

• Is used in transporting material found by the Secretary of Transportation to be hazardous under 49 U.S.C. 5103 and transported in a quantity requiring placarding under regulations prescribed by the Secretary under 49 CFR, subtitle B, chapter I, subchapter C.

©2014 MFMER | 3212718-33

Interstate Commerce

• Commerce means (a) any trade, traffic or transportation within the jurisdiction of the United States between a place in a State and a place outside of such State, including a place outside of the United States and (b) trade, traffic, and transportation in the United States which affects any trade, traffic, and transportation described in paragraph (a) of this definition.

• Drivers not subject to Federal regulations and participate solely in intrastate commerce are regulated by the State

• Medical examiners are responsible for knowing the requirements within the state they are practicing

©2014 MFMER | 3212718-34

Commercial Motor VehiclesCome in all shapes and sizes

©2014 MFMER | 3212718-35

Commercial Motor Carrier

• Motor carrier means a for-hire motor carrier or a private motor carrier.

• The term includes a motor carrier's agents, officers and representatives as well as employees responsible for hiring, supervising, training, assigning, or dispatching of drivers and employees concerned with the installation, inspection, and maintenance of motor vehicle equipment and/or accessories.

©2014 MFMER | 3212718-36

Commercial Motor Carrier

• The motor carrier must ensure that its drivers meet the standards outlined in 49 CFR 391.11 --

• Driver must be at least 21 years of age• Comprehend and use the English language• Must safely operate a commercial vehicle• Have only one valid CMV operator’s license• Current medical certificate must be on file (some request “long form”)• Collect appropriate background check and violation records from

driver (as described in 391.27)• Have completed a driver’s road test• Not currently disqualified to drive a CMV• Motor Carrier may impose other requirements such as minimum lifting

capability

©2014 MFMER | 3212718-37

©2014 MFMER | 3212718-38

FormsWhat should you know?

Form Completion (649-F)

• First, identify the driver

• Use appropriate Medical Examination Report form;

• Assure that driver completes and signs driver’s portion of the Medical Examination Report form;

• Review in detail any specifics regarding any affirmative response on the driver’s medical history;

©2012 MFMER | 3212718-39

Health History

• Driver must include lifetime history

• Any “YES” answer should be clarified below

• May add data onto separate page that is signed and dated

©2012 MFMER | 3212718-40

Make sure to include:• Height/weight, blood pressure, pulse;

• Details of abnormal findings;

• Audiometric and vision testing results;

• Presence or absence of a hearing aid and whether it is required to meet the standard;

• If obtained, funduscopic examination results;

• Document the need for corrective lenses for driving;

• Indicate presence or absence of monocular vision and need for a vision exemption;

©2014 MFMER | 3212718-41

Make sure to include:• If driver has diabetes mellitus and is insulin

dependent, the need for a diabetes exemption;

• Document results of other laboratory, pulmonary, cardiac testing performed; and outline the reason(s) for the disqualification and/or referral (if pertinent).

• Form should be completed in full (and as legible as possible)

• Forms need to be secured by ME for 3 years

• Form may be electronic but need to have ability to print all data on hard copy and present a medical card to driver

©2014 MFMER | 3212718-42

Physical Examination

©2014 MFMER | 3212718-43

• Driver must certify all responses are not falsified and that the form is complete

• An incomplete, misleading, or falsified form will invalidate the exam and resulting certificate

• Criminal and/or civil action may be pursued against the driver for false statements or failure to report a disqualifying condition

©2014 MFMER | 3212718-44

Medical Examiner Certificate

©2014 MFMER | 3212718-45

Medical Examiner’s Certificate(Make sure you have new format with line to include NRCME number)

Form 649-F “Long Form” includes all pages and supplemental attachments (e.g. test results)

©2014 MFMER | 3212718-46

WhatStressors do drivers

encounter?

Driving stressors are magnified by multiple factors

• Erratic schedules

• Environmental factors

• Types of cargo

• Driving exposure is extensive and involves many tasks

• Alertness• Use of spatial orientation• Steering wheel control• Gear shifting• Manipulate dashboard switches

and controls• Enter and exit the vehicle• Load, secure, and unload cargo• Perform vehicle inspections• Coupling and uncoupling trailers

©2014 MFMER | 3212718-47

Types of Driving Routes

Turn-around or Short Relay

Long-Relay or Regional

Straight through haul

©2014 MFMER | 3212718-48

Basic Parts of the Truck

©2014 MFMER | 3212718-49

Fifth Wheel

Kingpin Landing Gear Mud Guard

Exhaust stack

Glad Hands

The federal statute that outlines the physical requirements for a CMV driver is:

©2012 MFMER | 3212718-50

1 2 3 4

0% 0%0%0%

1. 49 CFR 391.45

2. FAR 61.53

3. 49 CFR 391.47

4. 49 CFR 391.41

Tasks requiring intact musculoskeletal system

• Climb into and out of the truck• Manipulating the steering wheel• Shifting gears• Maintaining pressure on pedals/braking• Performing pre and post safety checks• Ensuring the vehicle is loaded properly• Securing the load• Evaluating and managing vehicle breakdowns• Responding to weather or emergency situations

©2014 MFMER | 3212718-51

©2014 MFMER | 3212718-1



Education and CertificationSession 2

Session 2 Diagnostic Approaches in Assessing Medical Fitness of the Commercial Driver

• Strategies for Targeted History Taking and Efficient Physical Examinations

• Overview of Non-discretionary Disqualifying Conditions

• Organ System-based Review of Commonly Encountered Medical Conditions

©2014 MFMER | 3212718-2

In my practice I exam about _____ CMV drivers each year.

©2012 MFMER | 3212718-3

1 2 3 4 5

0% 0% 0%0%0%

1. <10

2. 10-20

3. 20-50

4. 50-100

5. >100

Of the drivers I evaluate, the estimated number who are issued 2-year certifications is:

©2012 MFMER | 3212718-4

1 2 3 4 5 6

0% 0% 0%0%0%0%

1. <10%

2. 10-25%

3. 25-50%

4. 50-75%

5. 75-90%

6. >90%

Physical examination

• Opportunity to re-review health history

• You can examine in “parallel,” not “series”

• You cannot examine what you cannot see --the patient needs to disrobe and gown up

• Creating an environment conducive to a good exam is very important (i.e. control background ambient noise, have professional setting, etc.)

©2014 MFMER | 3212718-5

Physical Examination Video

©2014 MFMER | 3212718-6

The “Final Four”

©2014 MFMER | 3212718-7

Visual acuity<20/40

<70º field of visionColor vision lossMonocular vision

Hearing acuityWhispered voice test

and audiometry

Epilepsy Diabetes requiring insulin

Non-discretionary standards that preclude driver certification

Which of the following conditions would be considered “non-discretionary” conditions resulting in medical disqualification of the commercial driver if present on exam?

©2012 MFMER | 3212718-8

1 2 3 4 5

0% 0% 0%0%0%

1. Coarctation of the aorta

2. Vertigo

3. 2 unexplained seizures in prior 3 years

4. Type II diabetes

5. Stage I Hypertension

Vision Requirements:

• Distant vision 20/40 (Snellen) in each eye separately and concurrently with or without correction

• Field of vision of at least 70º in the horizontal median for each eye

• Ability to recognize the colors of traffic signals and devices showing red, green, and amber

©2014 MFMER | 3212718-9

Vision • If corrective lenses

required to meet standard, those lenses must be worn while driving

• Optometrist, ophthalmologist, or ME/designate may perform testing but ME makes final certification determination

• Monocular vision is considered disqualifying but may be acceptable for exemption

©2014 MFMER | 3212718-10

Visual acuity

©2014 MFMER | 3212718-11

• Visual perception may be challenging due to extended exposure at the wheel, need for spatial orientation, use of mirrors, long turning radius, presence of blind spots, extended stopping times

• History should include questions regarding medication for eye disorders

• May use any variety of types of charts that measure acuity or an alternative visual acuity measurement device

©2014 MFMER | 3212718-12

©2012 MFMER | 3212718-13

©2012 MFMER | 3212718-14

©2014 MFMER | 3212718-15

©2014 MFMER | 3212718-16

Key History Points:• Current over-the-counter (OTC) and prescription medications or supplements

including potential side effects.• Eye disorders and/or family history of eye disorders (e.g. monocular vision,

retinopathy, cataracts, glaucoma, strabismus, macular degeneration) • Corrective lens (contacts or glasses); accommodation for color blindness• Past medical history in addition to eye disorders including diabetes,

hypertension, thyroid disorders. • Exposures to direct sun exposure, smoking, trauma from recreational activities;

sports or hunting.

Eye abnormalities to screen and discuss with driver

• Cataracts

• Aphakia

• Nystagmus

• Ocular muscle imbalance

• Glaucoma

• Macular Degeneration

• Retinopathy

©2014 MFMER | 3212718-17

©2014 MFMER | 3212718-18

©2014 MFMER | 3212718-19

©2014 MFMER | 3212718-20

©2014 MFMER | 3212718-21

Phoria Testing

©2014 MFMER | 3212718-22

Phoria exams test the natural position of the eyes. If you have a normal visual system, both eyes point the same direction. There are two factors that make this happen -- the attachment of the six muscles to the eye; and the brain’s ability to force the eyes to work together to see one image. During a phoria test, the second factor is eliminated.

©2014 MFMER | 3212718-23

Strabismus• Also known as squint, lazy eye and heterotropia is a condition in which the

eyes are not properly aligned with each other. It typically involves a lack of coordination between the extraocular muscles, which prevents bringing the gaze of each eye to the same point in space and thus hampers proper binocular vision, and which may adversely affect depth perception.

Amblyopia• Also known as lazy eye, is an eye disorder characterized by an impaired vision

in an eye that otherwise appears normal, or out of proportion to associated structural abnormalities of the eye. In amblyopia, visual stimulation either fails to transmit or is poorly transmitted through the optic nerve to the brain for a continuous period of time. It can also occur when the brain "turns off" the visual processing of one eye to prevent double-vision, for example in strabismus (crossed-eyes). It often occurs during early childhood, resulting in poor or blurry vision. Amblyopia normally affects only one eye in most patients.

Federal Vision Exemption Program• Used for monocular vision

• Driver must be fully qualified under 49 CFR 391.41(b)(1-13) in order to be eligible for exemption

• Must have annual medical examination

• Eye evaluation from ophthalmologist and/or optometrist

• Motor carrier must make sure driver has required certification prior to operating CMV

©2014 MFMER | 3212718-24

©2014 MFMER | 3212718-25

X Vision

507-555-1234

10/27/2013

Bill Feelgood, DO

13275 MN

X

1234567812

Billy Jo Driver X X

P345762348901 MN

123 Lazy Lane; Rochester, MN 55905

10/27/2014

William A. Feelgood

Billy Jo Driver

….Qualified by Operation of 49 CFR 391.64

aka the “Federal Vision Exemption Grandfathering” Program

• Occurred 1992 to 1996 as a vision study program

• Total of 2,656 drivers were granted a participation certificate for monocular vision, provided the driver remained otherwise qualified

• Driver must bring eye evaluation from specialist

• Maximum certification is one year

©2014 MFMER | 3212718-26

A 39-year-old CMV driver comes to your office. She has monocular vision from a hunting accident three months prior but no other abnormalities. She brings a valid vision exemption form with her. You should…

©2012 MFMER | 3212718-27

1 2 3 4

0% 0%0%0%

1. Defer the medical to the State DOT

2. Issue a 3-month certificate

3. Issue the certificate with need for vision exemption (1-year)

4. Do not issue certificate

• INSERT PHOTO OF EAR EXAM

©2014 MFMER | 3212718-28

Which of the following is CORRECT regarding voice testing for CMV drivers?

©2012 MFMER | 3212718-29

1 2 3 4

0% 0%0%0%

1. Should be done no more than 5 ft from driver

2. Should avoid using sibilants during testing

3. Failure to pass the whisper test results in disqualification

4. Conversational voice must be utilized

Hearing • Driver must have auditory

acuity that allows,• Whispered voice > or =

5 feet or….• Audiometry does not show

average hearing loss > 40 dB at 500 Hz, 1000 Hz, and 2000 Hz with or without hearing amplification device –calibrated to

ANSI Z24.5 – 1951• Either test can be utilized

first, and the other is not required if standard met

©2014 MFMER | 3212718-30

• If both tests of hearing failed, then disqualified

Hearing• Whisper Test – the examiner stands at least 5 feet

from the driver

• Each ear is tested individually. The ear being tested is turned toward the examiner, and the other ear is covered.

• The examiner should not use sibilants (s-sounding words or numbers).

©2014 MFMER | 3212718-31

Examples of words/letters/numbers that are silibants:speech sound such as s, z, sh, or zh

Examples of preferred words/letters/numbers to use for the whisper test (non-silibants):

applerainfall

©2014 MFMER | 3212718-32

Remember your audiometric conversions -- and that averaging

calculation for the three frequencies must be <40 dB !!

©2014 MFMER | 3212718-33

Wavelength (Hz) Sound detection (dB) – Left ear

Sound detection (dB) – Right ear

500 20 20

1,000 40 50

2,000 50 55

3,000 70 90

Patient #1 ANSI scale measurements

Would you certify Patient #1?

©2014 MFMER | 3212718-34

1 2

0%0%

1. Yes

2. No

Yes, certify!• Left ear is: 20 + 40 + 50 = 110/3 = 36.67

(which is < 40 dB)

• Right ear is: 20 + 50 + 55 = 125/3 = 41.67

Remember: For FMCSA exams, you do NOT care about any other frequencies but 500, 1000 and 2000 Hz. Any other frequency given does not get pulled into the calculation.

Always use the ear with the best acuity for the calculation.

If in ANSI scale, take the average of the three readings –otherwise convert from ISO to ANSI (-14, -10, -8.5 dB conversion).

©2014 MFMER | 3212718-35

©2014 MFMER | 3212718-36

Wavelength (Hz) Sound detection (dB) – Left ear

Sound detection (dB) – Right ear

500 10 20

1,000 45 50

2,000 70 55

3,000 35 90

Patient #2 ANSI scale measurements

Would you certify Patient #2?

©2014 MFMER | 3212718-37

1 2

0%0%

1. Yes

2. No

No, do not certify! (refer for further hearing evaluation)

• Left : 10 + 45 + 70 = 125/3 = 41.67

• Right: 20 + 50 + 55 = 125/3 = 41.67

(does not meet <40 dB standard)

So, the driver would need to be tested with hearing amplification as recommended by an audiologist or ENT professional…

©2014 MFMER | 3212718-38

Generally disqualifying otic conditions

©2014 MFMER | 3212718-39

• Vertigo (uncontrolled)

• Meniere’s Disease

• Labyrinthine Fistula

• Nonfunctioning Labyrinth **Driver should not drive for at least 2 months after Benign

Positional Vertigo or Peripheral Vestibulopathy

Diabetes mellitus and other Endocrine Disorders

©2014 MFMER | 3212718-40

Diabetes Mellitus49 CFR 391.41 (b)(3)

• Driver with insulin-dependent diabetes is disqualified medically

• More than 23 million people (7.8% of population) have diabetes – and many more likely remain undiagnosed

• Type II DM – adult onset • Can produce insulin and retain many glycemic

control mechanisms• With progression of disease, may require insulin• Hypoglycemic detection is the most important aspect

of management for safety purposes

©2014 MFMER | 3212718-41

Lifestyle issues are major determinant of long-term treatment success

• Elevated glycemic index (HbA1c)

• Hyperglycemia may lead to neuropathy, retinopathy, nephropathy, PVD, CAD, lethargy, fatigue

• Hypoglycemia is a critical safety issue for drivers that may result in seizure, impaired cognition, etc.

©2014 MFMER | 3212718-42

Important Health History Questions for Diabetic Drivers

• Do you use medication to control blood sugars (including incretin mimetics like Byetta [exenatide])?

• Do you monitor your blood sugar levels?

• History of fainting, dizziness, or LOC?

• If so, how many times in past year? 5 years?

• Look for: Glycosuria (on urine dip), Macular degeneration, Peripheral neuropathy, Nephropathy? TIA or stroke history?

©2014 MFMER | 3212718-43

Federal Diabetes Exemption Program49 CFR 391.64(a)

• Group of drivers who were participants in good standing in March 1996 were provided a letter grandfathering them with an exemption as long as they remained compliant with requirements

• By September 2003, the FMCSA then approved issuing exemptions to diabetics if the driver met all guidelines other than insulin use

• Federal Diabetes Exemption Program is responsible for establishing driver eligibility and issues the exemption

• Exemption must be renewed every 2 years

• But every year the driver needs: ME exam, diabetologist eval, Eye eval, education for diabetes

©2014 MFMER | 3212718-44

©2014 MFMER | 3212718-45

A 59-year-old over-the-road tractor-trailer driver comes to your office for a DOT evaluation. He says he had “borderline diabetes” several years prior. He is noted to have trace glucose in his urine dip. Further studies show a creatinine of 1.3 mg/dL, hemoglobin A1c of 8.2%, and no peripheral neuropathy. An eye evaluation is normal. Is taking no oral or injectable hypoglycemic agents. What is the next best step in assessing the driver?

©2014 MFMER | 3212718-46

What would be your next move?

©2014 MFMER | 3212718-47

1 2 3 4

0% 0%0%0%

1. Issue certificate and refer to his primary provider to initiate comprehensive evaluation & treatment of diabetes

2. Issue a 3-month certificate and recheck HbA1c

3. Disqualify driver since he cannot be certified with diabetes

4. Refer driver to the Federal Diabetes Exemption Program

©2014 MFMER | 3212718-48

Blood pressure and Medical Certification of CMV Drivers

Hypertension

• 49 CFR 391.41(b) (6) A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of high blood pressure likely to interfere with ability to operate a commercial vehicle.

CMV Driver Medical ExaminationMeasuring Blood Pressure• Factors that may contribute to inaccurate BP

readings: e.g. too small or large of a cuff, driver feeling anxious, just having had a tobacco product just prior to coming for exam

• To allow for an accurate measurement of an elevated blood pressure finding, there should be a confirmation of this reading by at least two subsequent measurements on the same day

• FMCSA considers two elevated BP readings at consecutive examinations, whether follow-up or recertification, as readings that confirm an elevated BP

Hypertension- Identification & History

• Hypertension is diagnosed as two readings greater than 140/90.

• Affects over one billion individuals worldwide and increases with age.

• History should include any OTC medications used as well as prescription medication & supplements including potential side effects which may be potentially disqualifying.

• Cardiovascular co-morbidities including HTN, congestive heart failure, myocardial infarction, coronary insufficiency, or thrombosis

Hypertension- Risk Identification

• When documenting medical conditions, consider rate of progression, degree of control and likelihood of sudden incapacitation.

• Hypertension significantly contributes to cardiovascular morbidity and mortality by causing substantial structural and functional adaptations, including left ventricular diastolic dysfunction.

• Unlikely to cause a sudden collapse, however the likelihood increases when target organ damage, particularly if cerebral vascular disease is present.

• Hypertension and aging contribute significantly to adverse cardiac morphology and poor outcomes.

Hypertension- Risk Identification (cont.)

• Hypertension in the setting of target organ damage requires further assessment to determine functional status of the driver.

• Ideally all drivers applying for medical certification to drive a CMV should have a serum creatinine test with calculation of the Glomerular Filtration Rate (GFR) in order to determine if renal disease is present to determine the stage of the disorder.

Hypertension- Certification Outcomes and Intervals

• Driver is required to have an exam done at least annually.

• Disqualify a driver when evidence shows a condition exists that will likely interfere with the safe operation of a CMV, which, may include sufficient supporting opinions and information from appropriate specialists.

• Document the reasons for disqualification and/or referral.

• Advise a driver certified with a limited interval to return for recertification with documentation for the stated condition.

Hypertension

• All CMV drivers should be referred to their personal provider for therapy, education, and long-term management

• Medical Expert Panel (MEP) recommended that the medical examiner should ensure that individuals with hypertension are properly educated about the importance of making changes in lifestyle and proper compliance with medication

Medical Examiner’s Role

• Use hypertension guidelines to determine medical fitness for duty

• Review driver’s medications including tolerance, effectiveness, dosage

Hypertension Standards Objectives

FMCSA recognizes three stages of hypertension:

• Stage 1: BP 140-159/90-99. Certification period - 1 year

• Stage 2: BP 160-179/100-109. Certification period - 3 month as a one time certificate. Within 3 months if the BP is below 140/90 may receive a one year certificate.

• Stage 3: BP >180/110. This is a disqualifier. Driver may be certified if BP is less than 140/90 at 6 month intervals.

Malignant Hypertension

• Clinical presentation: patient appears ill, often complains of a HA, blurred vision, dyspnea, and chest pain.

• Left untreated, may result in acute renal failure, MI, cerebral hemorrhage, severe cardiac decompensation, or hypertensive encephalopathy.

• On physical exam: along with the severely elevated BP, may have rales in the lung bases, marked retinal findings are often present.

Malignant Hypertension - Diagnostic tests and referral

• Chemistry panel

• Note any elevation in BUN and creatinine

• UA- assess for hematuria and proteinuria

• EKG

• Chest X-ray

• May need further evaluation including renal studies

• All patients with this condition need to be hospitalized

• If patient presents to clinic, call ambulance for a transfer to ED for further evaluation

Hypertension and the Driver Medical History- Documentation

• Confirm with driver the reason for taking an anti-hypertensive and advise follow up with PCP for monitoring of medication

• Potential medication side effects of somnolence or syncope are particularly undesirable in commercial drivers

• Discuss lifestyle changes such as weight reduction, increased exercise, tobacco cessation – and document response

• Treatment includes nonpharmacologic and pharmacologic modalities as well as counseling to reduce other risk factors

A 46-year-old obese milk truck driver is noted to have a bp of 130/82 in the office during his DOT medical exam. He is on lisinopril at 10 mg daily after being noted to have an average bp of 142/92 on initial exam.

What is the next best step?

©2012 MFMER | 3212718-61

1 2 3 4

0% 0%0%0%

1. Issue a 3-month certificate and have him return within 1 week of bp readings

2. Issue a one-year certificate

3. Refer him to his cardiologist

4. Issue a two-year certificate

Determining Certification for HypertensionStandard Objectives

• The regulatory criteria is based on FMCSA’s Cardiovascular Advisory Guidelines for the Examination of CMV drivers which used the JNC-6 Report on Detection, Evaluation, and Treatment of High Blood Pressure.

• These requirements and guidelines developed by the FMCSA are designed to assist the ME in making qualification determination.

• There are many times a ME might shorten the recommended certification process based on the FMCSA’s Advisory Guidelines which may include the presence of multiple co-morbidities and evidence of target organ damage.

©2014 MFMER | 3212718-63

Laboratory Testing at Time of Exam- Urinalysis

• Proteinuria• Glycosuria• Hemoglobinuria

©2014 MFMER | 3212718-1




Commercial Driver Medical Examination and Certification

Cardiovascular

Evaluation

49 CFR 391.41(b)(4)

A person is physically qualified to drive a commercial motor vehicle (CMV) if that person…

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

Cardiovascular Recommendations

• Definition of current generally means a diagnosis within the last 3 months, or a diagnosis that is not stable at the time of exam.

“Medical fitness for duty includes the ability to perform strenuous labor. Overall requirements for commercial drivers, as well as the specific requirements in the job description of the driver, should be deciding factors in the certification process.”

Cardiovascular DiseaseAdvisory Criteria

Cardiovascular DiseaseAdvisory Criteria

• Cardiovascular insufficiency should be evaluated, looking for:

• No physical limitations• No residual symptoms• No medications likely to impair abilities• May be evident by normal resting and stress

ECG

• Implantable defibrillators are disqualifying

• Coumadin is allowed as part of medical treatment (but need therapeutic INRs) and novel anticoagulant agents are acceptable

Cardiovascular Disease- Taking a detailed history

Is there ……• A current clinical diagnosis

of myocardial infarction, angina pectoris, coronary insufficiency or thrombosis

• Syncope, dyspnea, or collapse

• Heart failure

• History of heart disease, or acute myocardial infarction

• History of other heart conditions

• History of heart surgery, including valve replacement/bypass, angioplasty, implantable cardiac defibrillator or pacemaker

• Use of any cardiovascular medication that effectively controls a condition, and any side effects from the medication that may interfere with safe driving

Cardiovascular Disease- Medical Examiner responsibilities

Examination should include evaluation and documentation of:• Murmurs• Arrhythmias• Cardiomegaly• Evidence of surgical intervention• Evidence of congestive heart failure• “An electrocardiogram (ECG) is required when

findings so indicate”

Cardiovascular Disease

• Diagnostic Testing• Electrocardiogram, Exercise stress treadmill,

LV ejection fraction, vascular studies, blood tests (electrolytes, chemistries, toxicology) as indicated

• Chest x-ray• Drug level monitoring when indicated (Digoxin, INR)

• Referral• Refer a driver who exhibits evidence of a

cardiovascular disorder to another evaluating physician (primary care or cardiologist) when evidence of CV disorder present (e.g. MI, coronary insufficiency, hypertension)

Cardiovascular DiseaseGeneral guidelines for Test Results

• Exercise Stress test• Driver should exercise to greater than

6 Metabolic Equivalents (METS)• Attain a heart rate greater or equal to

85% of Maximum Predicted (unless on beta blocker)

NOTE: Max predicted is 220- driver’s age

• Have a rise in systolic pressure greater than or equal to 20mm Hgwithout angina

• Have no significant ST segment depression

Cardiovascular DiseaseGeneral guidelines for Test Results

• Echocardiogram• Left ventricular ejection fraction of 40% or more• No pulmonary hypertension

• Defined as pulmonary artery pressure greater than 50mm Hg as determined by echo or cardiac catheterization, or

• > 50% systolic pressure, although other criteria may be used

• ECG• No new evidence of myocardial infarction• If presence of arrhythmia, follow CV guidelines

Which of the following would preclude issuing a medical certificate to a driver after a myocardial infarction?

©2014 MFMER | 3212718-11

1 2 3 4

0% 0%0%0%

1. 3 months post-MI

2. Post-MI LVEF 35%

3. Taking 3 different anti-hypertensive medications

4. Exercised to 7 METS on Bruce protocol GXT

Cardiovascular Disease- Post MI

Can Certify if:• No symptoms• 2 months or more

after MI• LVEF ≥ 40%• Meds well tolerated• Cardiologist clears

One-Year Certification

Cardiovascular DiseaseAngina Pectoris

Can Certify if:• Stable angina• Asymptomatic

during work activities

1-year certification(with at least every other year get EST)

Cardiovascular DiseasePost Percutaneous Coronary Intervention

• Medical Expert Panel advisory currently does not distinguish between drug-eluting stents and bare metal stents.

Cardiovascular Disease- Post CABG

• Medical examiner may wish to inform specialist of pertinent criteria needed for certification

• Some examiners create a form letter with FMCSA regulations, and advisory criteria, asking specialist to provide documentation that the driver is not at increased risk for syncope, dyspnea, collapse or congestive heart failure

Drivers without known CHD

…But positive risk factors

Congenital Cardiovascular Disease

• See advisory criteria for specifics, maximum allowable 1 year certification if stable and no disqualifying features

• Annual review with cardiologist knowledgeable of adult congenital heart disease

• May need annual Holter and Echo

Cardiovascular DiseaseHeart Transplant

• May certify if at least 1 year from transplantation

• Asymptomatic

• Stable on medication

• No rejection

• Meets other criteria

• Certify every 6 months with evaluation by cardiologist

REMEMBER -- Any disorder with an Implantable Defibrillator

Certification NOT allowed

Mitral Valve Disease- Mitral stenosis

Mild to moderate:

(based on valve area*)

Certify if asymptomatic.

(One year maximum certification)

*Mild = MVA > 1.6 cm2

*Moderate = MVA 1 to 1.6 cm2

Severe: MVA < 1.0 cm2

• Post repair stand down depends on procedure and must be cleared by cardiologist

(4 weeks percutaneous valvotomy, 3 months sternotomy)

One year Maximum. Annual Cardiologist evaluation.

• If no surgery must have no evidence failure and evidence good exercise tolerance. See guidelines for details.

Mitral Valve Regurgitation

Mild and moderate:

• Ok to certify if asymptomatic andnormal LV size andfunction and normal PA pressure

• One year maximum

• Echo annually for moderate severity

Severe:

Ok to certify if asymptomatic & normal stress test & LV size and function + no atrial fibrillation, no flail leaflet, normal PA pressures.

One year maximum, Echo every 6 months to a year.

Post op: 3 months stand down and then must be cleared by cardiologist

Mild to Moderate: One year maximum certification

• Must be asymptomatic, Normal LV function

• (note LVEF = 50%) Minimal LV enlargement. Echo every 2 to 3 years

Severe:

• Can certify if…asymptomatic, LV function normal (EF 50%) & LV diameter not larger than 70mm at end diastole or 55mm end systole

• Must have good exercise tolerance

• Duration of certification depends on LV diameter.

6 months with Echo: LVEDD < 60 mmHg and LVESD < 50 mmHg

4 months with Echo: LVEDD = 60 mmHg or LVESD = 50 mmHg

Aortic Valve Regurgitation

Aortic valve stenosis

Mild severity (AVA > 1.5 cm2)

• May certify if asymptomatic

• Annual recertification

• Echo every 5 years

Note: if symptoms with this valve area you need further evaluation with explanation of symptoms to certify

Moderate severity (AVA > 1.0-1.5 cm2)

• May certify for one year if asymptomatic

• Recertify annually

• Echo every one to 2 years

• Post op stand down 3 months

Do not certify if severe aortic stenosis present (AVA <1.0 cm2).

Valve replacement

Mechanical valves can be certified if:

• 3 months post op

• asymptomatic

• cleared by a cardiologist

• seen annually by cardiologist

• one year DOT medical certification only

Do not certify if LV dysfunction, thromboembolic complication post procedure, pulmonary artery hypertension, or inadequate anticoagulation.

Supraventricular Tachycardia

• Atrial fibrillation as cause of or a risk for stroke

• Atrial fibrillation following thoracic surgery• Atrial flutter• Multifocal atrial tachycardia• Atrioventricular Nodal Reentrant Tachycardia• Atrioventricular Reentrant Tachycardia &

Wolff-Parkinson-White syndrome

Atrial arrhythmias

• Atrial fibrillation • 1 month after adequate/stable anticoagulation• Adequate rate control • Cleared by cardiologist• Recertification annually

• Atrial flutter• 1 month post-isthmus ablation• Recertify annually

• Multifocal atrial tachycardia• Ok, if asymptomatic• No, if symptomatic• Annual recertification

Remember…you still need to wait 3 months post sternotomy if atrial fibrillation is a post op phenomenon.

Ventricular arrhythmiasDiagnosis Physiology/

FunctionCertification Recertification

Coronary Heart Disease (CHD)

Sustained VT:Poor prognosis and highrisk.

NSVT, LVEF <0.40:Unfavorable prognosis.

NSVT, LVEF ≥0.40:Generally considered tohave good prognosis.

No

No

No, if symptomatic.Yes if:Asymptomatic;At least 1 month afterdrug or other therapyis successful;Cleared bycardiologist.

Annual cardiology examination required

Dilated Cardiomyopathy NSVT (LVEF ≤0.40)

Sustained VT, anyLVEF.

Syncope/near syncope,any LVEF: High risk.

No

No

No

Hypertrophic Cardiomyopathy

Variable but uncertainprognosis.

Most Ventricular tachycardias are excluded.

In CHD, NSVT, with LVEF ≥0.40:Can certify if asymptomatic;At least 1 month afterdrug or other therapyis successful; and cleared bycardiologist.

Diagnosis Physiology Certification RecertificationRight Ventricular Outflow VT

Favorable prognosis and low risk for syncope

No, if symptomatic.

Yes, if asymptomatic.

Yes if:At least 1 month afterdrug or other therapysuccessful;Asymptomatic;Cleared byelectrophysiologist.

AnnualRecommend evaluationby cardiologist.AnnualEvaluation bycardiologist required.

Idiopathic Left Ventricular VT

Favorable prognosis and low risk for syncope

No, if symptomatic

Yes, if asymptomatic.

Yes if:At least 1 month aftersuccessful drugtherapy or ablation;Cleared byelectrophysiologist.

AnnualRecommend evaluationby cardiologist.AnnualEvaluation bycardiologist required.

Long QT Interval Syndrome

High risk for ventricular arrhythmic death

No

Brugada Syndrome High risk for ventricular arrhythmic death

No

Note certification criterion

Note recertification

criteriaDo not certify!

Pacemakers

• For sinus node dysfunction and atrioventricular block, long-term prognosis is variable depending on the underlying disease

• Hypoperfusion (if present) must be corrected by support of heart rate by pacemaker

• May certify for one year if one month after pacemaker implantation; need documented correct function and underlying disease is not disqualifying itself

• Recertify annually with documented pacemaker checks

Pacemakers and Syncope: Neurocardiogenic and Carotid Sinus Hypersensitivity

• Excellent Long term survival

• But risk for syncope that may be due to cardio inhibitory or vasodepressor components. Pacemaker will only affect cardioinhibitory component though it may decrease the impact of the vasodepressor component.

• Bottom line: a pacemaker may not completely resolve the problem

Ok to certify if asymptomatic, but need 3 months stand down, AND documented good pacemaker function

• Annual recertification required

• Must be asymptomatic

• Pacemaker checks documented

Venous disease

• DVT: do not certify if symptomatic

• For warfarin stand down one month for regulation and need at least monthly INR levels with >80% therapeutic

• Annual recertification

• Superficial Phlebitis – Ok to certify if DVT ruled out and no other disqualifying diseases

(routine recertification may be up to 2 years)

Cardiovascular DiseasePulmonary embolism & medical therapy

Aneurysms

©2012 MFMER | 3212718-33

Aneurysms

• Abdominal Aortic aneurysm• Evaluate for other risk for cardiac disease• <4.0 cm, annual recertification• 4.0-5.0 cm if asymptomatic and cleared by a

vascular surgeon who does not recommend surgery, annual recertification

• Do not certify if >5.0 cm, or symptomatic, regardless of size

If driver undergoes surgery….Must wait at least 3 months post surgery and cleared by cardiovascular specialist before medical exam. If acceptable, then needs annual recertification.

Aneurysms

• Thoracic aneurysm:• No certification if >3.5 cm, or symptomatic• At least 3 months post surgery and cleared

by cardiovascular specialist, annual certification

• May certify if < 3.5cm, asymptomatic, annual certification

• Other arterial vessels, determine risk of rupture, do not certify if symptomatic.

©2012 MFMER | 3212718-36

Respiratory Disorders

Includes:• Allergies & Asthma• Lung carcinoma• Chronic bronchitis/emphysema

(COPD)• Tobacco abuse

• Emphysema• Obstructive sleep apnea• Infectious respiratory conditions• Hypersensitivity pneumonitis

©2014 MFMER | 3212718-37

• Respiratory diseases may result in dysfunction and inability to remain alert

• Many medications used to treat respiratory conditions have untoward side effects

Respiratory Issues

Targeted History• Dyspnea?

• Bronchitic episodes?

• Pneumonias?

• Snoring or apneas?

• Daytime sleepiness?

• Smoker? How long and quantity?

• Cough?

• Supplemental O2?

• Wheezing?

Physical Exam Findings• Normal chest wall expansion?

• Respiratory rate?

• Cyanosis?

• Clubbing? Nicotine stains?

• Normal breath sounds?

• Significant kyphosis?

• Pleural friction rub?

• Use of accessory muscle of inspiration?

©2014 MFMER | 3212718-38

Respiratory Conditions

Allergy-related• Sinus – drivers cannot use

sedating anti-histamines• Anaphylaxis – stinging

insect allergy, should have Epi on board

Asthma• Must be clinically controlled

COPDPneumoniaTB or atypical infectionsCystic fibrosisILD

Pulmonary HTN• Significant if PA pressure is

>50% systolic bp

Pneumothorax

©2014 MFMER | 3212718-39

©2014 MFMER | 3212718-40

Indication to order spirometry:• Any specific lung disease• Dyspnea, cough, chest tightness, wheezing• Cigarette smoking in driver >35 years old

Pulse Ox and ABG indicated when:FEV1 < 65% predicted or FEV1/FVC <65%Restrictive physiology with FVC < 60%

Screening Pulse Ox:If < 92%, then ABGIf PaO2 <65mmHg at <5,000ft or <60 mmHg if > 5,000 ftOr pCO2 > 45 mmHg – do not certify

A driver with snoring, an elevated BMI and mild HTN should also be referred for….

©2012 MFMER | 3212718-41

1 2 3 4 5

0% 0% 0%0%0%

1. ABG

2. UPPP procedure

3. Polysomnography

4. Bronchoscopy

5. ECG with rhythm strip

Sleep apnea has been on the “radar screen” for a long time

• “Individuals with suspected or untreated sleep apnea (symptoms of snoring and hypersomnolence) should be considered medically unqualified to operate a commercial vehicle until the diagnosis has been dispelled or the condition has been treated successfully.

• In addition, as a condition of continuing qualification, commercial drivers who are being treated for sleep apnea should agree to continue uninterrupted therapy as long as they maintain their commercial driver’s license. They should also undergo yearly multiple sleep latency testing (MSLT).”

©2014 MFMER | 3212718-42

DOT/Federal Highway Administration's Conference onPulmonary/Respiratory Disorders and Commercial Drivers (1991):

©2012 MFMER | 3212718-43

Neck size > 17 in

50/50 rule- Half of OSAS patients have hypertension, half of hypertensive patients have OSAS

BMI > 125% of IBW

Mallampati Score

• View pharynx withmouth open at rest• No phonation orprotrusion of Tongue

Grade 1: Entire tonsil clearly visible Grade 2: Upper half of tonsil fossa visible Grade 3: Soft and Hard Palate clearly visible Grade 4: Only Hard Palate visible

Variable reliability in predicting apnea except at the extremes, but useful to document that you did the exam

Definitions of Sleep Disordered Breathing Events

ApneaThermal sensor amplitude drops ≥ 90% of baseline for at least

10 seconds

HypopneaNasal pressure amplitude drops ≥ 30% of baseline for at least

10 seconds with ≥ 4% desaturation from pre-event baseline

RERA- Respiratory Effort Related ArousalIncreasing respiratory effort OR flattening of nasal pressure

waveform for at least 10 seconds associated with arousalCriteria for apnea or hypopnea not fulfilled

- AASM 2007

OSA Severity

• Frequency of apneas and hypopneas

-Mild : 5-15 events per hour

-Moderate: > 15-30 events per hour

-Severe: > 30 events per hour

• Additional Measures

-Degree of nocturnal hypoxemia

-Extent of sleep fragmentation (e.g., arousal index)

47

CPAP

Wear CPAP or Die?

Risks of Untreated OSAS

He J. Chest 1988: 94:9

Apnea Index vs. Mortality• Probability of cumulative

survival in 142 patientswith AI< 20 (blue) vs. 104

patients (red) with AI> 20.

CPAP compliance• General

• Widely variable rates of 50-70% overall• Probably need >4 hrs. nightly for response

• Pattern 1: 6.2 hrs./night 90% of nights (50% pts)

• Pattern 2: 3.5 hrs./night 2-79% of nights• Compliance determined early on

Kribbs NB. Am Rev Respir Dis 1993; 147:887-895

Weaver TE. Sleep 1997;20(4):278-83

TreatmentOral Appliances

Silencer-Johns Dental Labs

Klearway-Great Lakes

Orthodontics

Mandibular devices Tongue device

Tongue retaining device-

Professional positioners

Treatment

Surgery

• Laser-assisted uvulopalatoplasty (LAUP)

• Uvulopalatopharyngoplasty (UPPP)

• Somnoplasty or Radiofrequency volumetric tissue reduction (RFVTR)

• Maxillofacial surgery

Maintenance of Wakefulness Test (MWT)

• Four sessions, 40 minutes each, at 2 hour intervals-Walk-in or previous night PSG

• Seated quietly on bed, dark room. Subject told to remain awake

• Nap terminated if any scorable sleep

• Though most fall asleep after much longer latency, 8-9% will fall asleep in < mean of 11 - 13 min

• Usual cutoff 19 min

• Most helpful outcome = no sleep

Other respiratory conditions

• Cystic fibrosis• Document any recent exacerbations of infection or

functional limitation

• Chest wall deformities• Significant kyphoscoliosis or pectus excavatum with

function limitation may require further evaluation

• Pneumothorax• Should have recent chest x-ray to document

resolution

©2014 MFMER | 3212718-54

©2012 MFMER | 3212718-55

Musculoskeletal conditions

• An extremely broad category of conditions, many with discretion of the medical examiner to decide the interval of examination

• Any condition with poor coordination, transient muscle weakness, or poor muscle tone may be disqualifying if it interferes with the ability to control and operate a CMV

• Consider the natural history and severity of the condition, any functional limitation, whether or not there is a risk for sudden incapacitation, or for progressive symptoms

©2014 MFMER | 3212718-56

©2012 MFMER | 3212718-57

Fixed Extremity Deficits

Require a Skill Performance Evaluation(SPE)

49 CFR 391.49

Need: • Long form of ME exam• Medical certificate copy (check

“SPE box”)• Medical evaluation summary by

board-certified PMR or Orthopedic specialist

• List of essential job functions from motor carrier

• Statement from provider re: precision prehension or power grasp prehension

©2014 MFMER | 3212718-58

Measuring grip strength

• May use a dynamometer

• Alternatively, use an office bp cuff bulb, having driver squeeze bulb repeatedly

©2014 MFMER | 3212718-59

©2012 MFMER | 3212718-60

Neurological Conditions 49 CFR 391.41(b)(7)(8)(9)• Seizure/Epilepsy• Severe headache• Vertigo / Dizziness• Head trauma or loss of consciousness• Neuromuscular conditions

Seizure history

©2014 MFMER | 3212718-61

Does driver have:• Childhood febrile seizures?• Provoked seizures? (e.g.

hypoglycemia, meds, anesthesia, fever)

• Unprovoked seizure?• Single episode?• 2 or more seizures (which

defines epilepsy)?

• Most seizures recur within 24 months of an initial trauma or focal insult• In stroke, 1 in 10 will have a seizure initially and up to 15% will within 5 years• Length of time seizure free and off all anti-seizure medication is most predictive of

probability of future seizures

NOTE: Drivers must be off meds and seizure-free for 5 years for a single unprovoked seizure, and seizure-free for 10 years and off drug for those with epilepsy.

Headaches

• Is a common condition, but rare that a headache would be disqualifying

• Important headache history includes: frequency, severity, anatomic location (e.g. parietal), association with nausea, emesis, visual disturbance, syncope, or cognitive or motor deficits

• Association with functionally-limiting sequelae or medications required to treat that result in side effects are considered disqualifying

©2014 MFMER | 3212718-62

Neuromuscular conditions• Must consider how the neuromuscular condition will

result in functional limitation (e.g. grasping, braking, clutching and coordination, climbing into and out of vehicles, reaction time)

• Refer to neurologist or PM&R specialist for information on prognosis or diagnosis

• Consider:• Motor neuron diseases (ALS, SMA, etc.)• Muscular dystropy• Neuromuscular junction abnormalities (Myasthenia gravis,

Eaton-Lambert)• Peripheral neuropathies• Congenital myopathies

©2014 MFMER | 3212718-63

Low back pain with radiculopathy

• Because it is a common condition, low back pain is not uncommonly seen by the medical examiner

• Review physical examination findings that are consistent with lumbar radiculopathy and be familiar with dermatomes and motor pathways

©2014 MFMER | 3212718-64

Dementia

• Published conference reports recommended any dementia be disqualifying, even if the diagnosis is seriously in the differential (not even proven)

• For individuals with very early symptoms or slow rate of progression, disqualification was deemed “mandatory” by the MEP

• All individuals with dementia-like symptoms need imaging of the brain and neuropsychiatric/cognitive testing

©2014 MFMER | 3212718-65

Stroke• Prevalent issue affecting > 3

million in the US each year

• Refer to a neurologist if not already seen

• Cortical and subcortical lesions are associated with increased seizure risk

• Brainstem and cerebellar infarcts not associated with seizure risk

• Disqualified for one year and require annual certification

For embolic stroke, TBI or bleeds, will need to consider neurocognitive testing within 90 days of DOT exam if there are any questions of memory loss or executive function.

©2014 MFMER | 3212718-66

• TIA requires 1 year stand down and neurology evaluation

©2014 MFMER | 3212718-67

This driver took a jump at full speed while impressing his girlfriend while snow boarding. Had loss of consciousness for 60 minutes after the injury. After surgical evacuation of the hematoma, he has remained seizure-free. He comes to you four months later and requests a DOT medical exam in hopes of working as a delivery truck driver.

Do you certify this driver?

Certify?

©2012 MFMER | 3212718-68

1 2

0%0%

1. Yes

2. No

©2014 MFMER | 3212718-69

Goals of Medication and Substance Use Review

• Identify illicit drug use

• Identify alcoholism

• Identify legal or prescribed drugs/substances which may impair driving or related medical condition which would lead to exclusion or other DOT consequence

• Exclude drivers with alcoholism, substance abuse and use of prohibited/impairing prescription drugs until they meet criteria for recertification

• Counsel drivers on risks of over-the-counter substances

49 CFR 391.41(b)(12)The Federal Motor Safety Regulations that address substance abuse and alcohol misuse [49 DFR 391.41(b)] state that a person is physically qualified to drive a commercial motor vehicle (CMV) if that person

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

(ii) Exception. A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who:

Is familiar with the drivers medical history and assigned duties; and

Has advised the driver that the prescribed substance or drug will not adversely affect the driver’s ability to safely operate a commercial motor vehicle; and

(13)Has no current diagnosis of alcoholism.

©2014 MFMER | 3212718-70

Targeted history directed at driver

• Ask: current use, recent drug treatment, legal issues pending.

• Ask: ever used, ever in drug or alcohol treatment, ever had DUI or other legal issues related to chemicals.

• See: if the individual is currently under the influence behavior may be erratic, pupils dilated or pinpoint depending on drug of choice (more likely they will not come currently using).

• See (not an exhaustive list):• Methamphetamine: skin lesions poor dentition• Injection drugs: needle tracks• Cocaine nasal findings

©2014 MFMER | 3212718-71

“Meth” Mouth and “meth” mites

©2014 MFMER | 3212718-72

Lets be real…..and really careful

• You should ask

• You should look

• But obvious findings aside, what else can you do? • Is your driver accident prone? (falls, fractures etc?)• An early MI without risk factors?

If you are concerned you may do what ever testing you feel you need to sort out the issue.

©2014 MFMER | 3212718-73

Current diagnosis of alcoholism

• For purposes of deciding on a “current” diagnosis of alcoholism, active participation in AA or other self help is not a reason to disqualify

• Should be sober and have completed treatmentand be medically stable from the consequences of alcoholism

• If you have a question about fitness to drive, refer to a Substance Abuse Professional

©2014 MFMER | 3212718-74

Alcoholism

• Use a screening test of choice• CAGE• TWEAK • AuditCan be done as screening form in your practice on all drivers

©2014 MFMER | 3212718-75

If you identify active substance or alcohol abuse

• Disqualify

• Refer to a substance abuse professional SAP

• Return to driving will require successful treatment and negative drug testing

• The examiner may certify the driver for less than 2 years if there is concern for relapse

©2014 MFMER | 3212718-76

Prescription medications that are narcotic, amphetamine, or habit forming

• State of the science is lacking

• The state of policy/statute is lacking• Disqualify unless there is a written document

from the prescriber stating that the substance will not affect the drivers ability to safely operate a commercial motor vehicle

©2014 MFMER | 3212718-77

What do we know• Stimulants may not have an effect on driving safety

• Opioids have a deleterious effect initially (consider a delay of driving with a new prescription and avoid intermittent use)

• Barbiturates do not have enough evidence to establish a safety risk

• Provigil (see FAQ’s in Tool Kit and FMCSA web site) • Drivers using this drug should not be qualified until

they have been monitored closely for at least 6 weeks. The treating provider and the medical examiner should agree that the Provigil is effective in preventing daytime somnolence, and that there are no side effects.

©2014 MFMER | 3212718-78

Expert Panel recommendations on medications

• Other expert panels have given recommendations regarding the use of psychoactive medications including benzodiazepines and antipsychotics

• Certain antihypertensives

• More than 500 prescription drugs have a sedation warning

• Sleep driving is a real issue for certain legal prescription drugs

©2014 MFMER | 3212718-79

Absolutes

• Methadone is an absolute disqualification

• Medical marijuana is an absolute disqualification

©2014 MFMER | 3212718-80

Counseling regarding use of medications

• You must counsel the driver to use medications as prescribed

• Drivers must be careful about over-the-counter medications which may be more impairing than prescription drugs

• Of specific concern -- sedating antihistamines • Use of a single dose of sedating antihistamine has

been shown to be more impairing than illegal level of alcohol

• Use of someone else’s prescription drug is unlawful and disqualifying for unauthorized use

©2014 MFMER | 3212718-81

Benzodiazepines

• There is good evidence that benzodiazepines are associated with an increased incidence of road accidents.

©2014 MFMER | 3212718-82

Pramipexole and ropinirole

• Associated with sleep attacks that are unpredictable and have occurred one year after beginning the medication – therefore, disqualifying at this time

©2014 MFMER | 3212718-83

©2014 MFMER | 3212718-1




©2014 MFMER | 3212718-2

WhatIs my role as a Medical

Examiner?

Split Roles of the Medical ExaminerDriver advocate vs. “forensic scrutinizer”

As a medical examiner the fundamental obligation is to establish

whether the driver has a condition resulting in a higher than acceptable

likelihood for gradual or sudden incapacitation or sudden death, thus

endangering public safety (i.e. a “medical fitness for duty” exam).

©2014 MFMER | 3212718-3

©2014 MFMER | 3212718-4

*from the FMCSA Medical Examiner’s Handbook

Split Roles of the Medical ExaminerDriver advocate vs. “forensic scrutinizer”

• Any time a driver, in your opinion, poses a risk to public safety, you should not certify the driver as medically fit for duty.

• As you conduct the physical examination to determine if the driver is medically fit to perform the job of commercial driving, you must consider:

Physical conditions

Mental conditions

Medical treatments (and side effects)

©2014 MFMER | 3212718-5

Physical condition • Symptoms — Does a benign underlying condition with an excellent prognosis

have symptoms that interfere with the ability to drive (e.g., a benign supraventricular arrhythmia that causes syncope)?

• Incapacitation — Is the onset of incapacitating symptoms so rapid that symptoms interfere with safe driving, or can the driver stop the vehicle safely before becoming incapacitated? Is the onset of incapacitating symptoms so gradual that the driver is unaware of diminished capabilities, thus adversely impacting safe driving?

Mental condition • Cognitive — Can the driver process environmental cues rapidly and make

appropriate responses, independently solve problems, and function in a dynamic environment?

• Behavior — Are the driver interactions appropriate, responsible, and nonviolent?

Medical treatment (and side effects) • Effects — Does treatment allow the driver to perform tasks safer than without

treatment?• Side effects — Do side effects interfere with safe driving (e.g., drowsiness,

dizziness, orthostatic hypotension, blurred vision, and changes in mental status)?

©2014 MFMER | 3212718-6

Split Roles of the Medical ExaminerDriver advocate vs. Forensic scrutinizer

• As the medical examiner, you are examining for medical fitness for duty, not diagnosing and treating personal medical conditions.

©2014 MFMER | 3212718-7

Drivers must:• Comply with FMCSA regulations.• Seek further testing/evaluations for those medical conditions of which you are

unsure.• Refer the driver to his/her personal health-care provider for diagnosis and

treatment of potential medical conditions discovered during your examination.• Promote public safety by educating the driver about:

• Side effects caused by the use of prescription and/or over-the-counter medications.

• Medication warning labels and how to read them.• The importance of seeking appropriate intervention for non-disqualifying

conditions, especially those that, if neglected, could result in serious illness and possible future disqualification.

Protected Health Information (PHI)

• Although regulatory requirements trump rules under HIPPA (Health Insurance Portability & Accountability Act of 1996), specific inquiries regarding what can be turned over to the employer should be directed toward appropriate legal counsel

• Although the Federal Motor Carrier Safety regulations do not require the medical examiner to give a copy of the Medical Examination Report form to the employer, the FMCSA does not prohibit employers from obtaining copies of the Medical Examination Report form.

• Medical examiners should have a release form signed by the driver if the employer wishes to obtain a copy of the Medical Examination Report form.

• Employers must comply with applicable State and Federal laws regarding the privacy and maintenance of employee medical information.

©2014 MFMER | 3212718-8

©2012 MFMER | 3212718-9

Cases

58-year-old male with interstitial lung disease requests to drive a school bus part-time.

©2014 MFMER | 3212718-10

• FEV1 is 0.95 L (30% predicted)• On 4L/min supplemental O2 via NC with measured

SpO2 of 96%• On lung transplant list• Job description reads, “Walk up 3 steps. Sit 45

minutes. Walk down 3 steps.”

Would you certify this man?

As the medical examiner (ME), I would…

©2014 MFMER | 3212718-11

1 2 3 4 5

0% 0% 0%0%0%

1. Certify for 2 years

2. Certify for 1 year

3. Certify for 6 months

4. Certify for 3 months and request more medical records

5. Do not certify

67-year-old man has indicated that he experiences intermittent chest pain that is worse with exertion and relieved with rest. It is substernal and occasionally radiates to his left arm. A 12-lead ECG is unremarkable.

©2014 MFMER | 3212718-12

After placing the exam in abeyance (or temporarily disqualifying), what testing would you do next?

©2014 MFMER | 3212718-13

1 2 3 4 5

0% 0% 0%0%0%

1. Lung scan (V/Q)

2. Echocardiogram

3. Exercise stress test

4. Coronary angiogram

5. EGD

Auditory Testing Results

Screening Test

• Whispered voice test is 3 feet in the worst ear

• Whispered voice test is 4 feet in the best ear

©2014 MFMER | 3212718-14

Would you certify this driver?

©2014 MFMER | 3212718-15

1 2 3

0% 0%0%

1. No, disqualify.

2. Yes, meets standards.

3. No, but need to do audiometry

AudiogramLeft Ear

500 Hz 20 dB

1000 Hz 60 dB

2000 Hz 70 dB

Right Ear

500 Hz 30 dB

1000 Hz 40 dB

2000 Hz 50 dB

©2014 MFMER | 3212718-16

Would you certify based upon audiometry results?

©2014 MFMER | 3212718-17

1 2 3

0% 0%0%

1. Yes

2. No

3. Defer exam to State DOT for further input.

52 year old female quit her job as a medical secretary because it was not exciting enough, and decided to become an OTR truck driver.

Examination reveals bilateral numbness and tingling of her hands.

What are some things you might consider based upon examination?

©2014 MFMER | 3212718-18

60-year-old male regional hauler moving new automobiles was treated for a myocardial infarction 3 months ago. He is asymptomatic and had completed cardiac rehabilitation. His blood pressure is normal, he remains asymptomatic, and has no musculoskeletal issues.

©2014 MFMER | 3212718-19

Which of the following findings would prevent him from being certified right now?

©2014 MFMER | 3212718-20

1 2 3 4

0% 0%0%0%

1. LVEF of 35% on echo

2. Only 3 months out from MI

3. Brief runs of ventricular tachycardia at the time he received thrombolytics

4. Exercise for 9 minutes on a full Bruce protocol treadmill

46 year-old obese male falls asleep in your waiting room filling out his insurance forms. He explains that he has always been a person who takes a “cat nap” in the afternoon. Exam shows an obese male with a BMI of 48 kg/m3. Mallampati IV/IV posterior oropharynx identified. Large, protuberant abdomen is noted. When asked, neck size is 18 1/2 in.

©2014 MFMER | 3212718-21

After completing the exam and reviewing his history, what do you do next?

©2014 MFMER | 3212718-22

1 2 3 4

0% 0%0%0%

1. Refer for stress echocardiogram

2. Order overnight pulse oximetry

3. Consult cardiology

4. Check fasting glucose.

You see a driver you have known for 20 years who has been documented to have mild essential HTN and who has been on lisinopril at 10 mg daily for the past 10 years. There have been no changes in his health and his exam is unremarkable. His blood pressure in the office is 136/78. You go ahead and issue the driver a certificate valid for 2 years.

©2014 MFMER | 3212718-23

Is issuing this medical certificate for 2 full years legal?

©2014 MFMER | 3212718-24

1 2

0%0%

1. Yes

2. No

You see a 67-year-old male driver for a CMV medical. He states he has no medical issues. However, on exam you note he has a glass eye. Exam is otherwise normal. What should you do?

©2014 MFMER | 3212718-25

1. Deny the certificate.

2. Certify for 3 months.

3. Certify with need for vision exemption.

4. Defer medical application to the FMCSA.

©2014 MFMER | 3212718-1




©2014 MFMER | 3212718-2

RegisteringFor the Exam

What you need to do• Register on the NRCME to get your

examiner number

• Sign up and select date for the exam on line• Find convenient testing center and pay

fee• Have available a copy of medical

license, proof of course completion, approved governmental ID

©2014 MFMER | 3212718-3

©2012 MFMER | 3212718-4

©2012 MFMER | 3212718-5

©2012 MFMER | 3212718-6

©2012 MFMER | 3212718-7

©2012 MFMER | 3212718-8

©2012 MFMER | 3212718-9

©2012 MFMER | 3212718-10

©2012 MFMER | 3212718-11

©2012 MFMER | 3212718-12

©2014 MFMER | 3212718-13

©2012 MFMER | 3212718-14

©2012 MFMER | 3212718-15

©2012 MFMER | 3212718-16

©2012 MFMER | 3212718-17

©2012 MFMER | 3212718-18

©2014 MFMER | 3212718-19

©2014 MFMER | 3212718-20

©2012 MFMER | 3212718-21

What you will be required to do once validated

• Once every calendar month, each medical examiner listed on the National Registry is required to complete and transmit to FMCSA a Form MCSA-5850, CMV Driver Medical Examination Results, with the following information about each CMV driver examined during the previous month:

• Name

• Date of birth

• Driver’s license number and State

• Date of examination

©2014 MFMER | 3212718-22

• An indication of the examination outcome (for example, medically qualified)

• Whether the driver is an intrastate driver only

• Whether the driver is a CDL holder

• Date of driver medical certification expiration

• Any restrictions and variances (for example, wearing corrective lenses or driving within an exempt intra-city zone)

©2012 MFMER | 3212718-23

What you will be required to do once validated(cont.)

You must submit this data electronically via a secure FMCSA-designated website. In order to continue to be listed on and to continue participation in the National Registry, you need to comply with this requirement on a monthly basis. If you have not conducted any exams during the month, that must be reported as well.

©2014 MFMER | 3212718-24

You will be required to take training every 5 years and an exam every 10 years.

Performance monitoring

• Medical examiners must provide Medical Examination Reports and medical examiner’s certificates to an authorized representative, special agent, or investigator of FMCSA or an authorized State or local enforcement agency representative to ensure compliance with FMCSA medical standards and guidelines in performing CMV driver medical examinations. FMCSA monitors medical examiner performance by:

• Conducting periodic reviews of randomly selected medical examiners listed on the National Registry Website to ensure that CMV driver examinations are being conducted properly.

• Periodically reviewing a representative sample of the Medical Examination Reports associated with the name and numerical identifiers of applicants/drivers for errors, omissions, or other indications of improper certification.

©2014 MFMER | 3212718-25

Performance monitoring (cont.)

• To comply with performance monitoring, you must: • Retain each original (paper or electronic) completed

Medical Examination Report and a copy or electronic version of each medical examiner's certificate on file for at least 3 years from the date of the of examination.

• Make all records and information in these files available to an authorized representative of FMCSA or an authorized Federal, State, or local enforcement agency representative, within 48 hours after the request is made for investigations and within 10 days of requests for regular audits.

©2014 MFMER | 3212718-26

©2012 MFMER | 3212718-27

Thanks for your participation!

1

Toolbox Links

FMCSA Tools

**Medical Examiner Handbook

http://nrcme.fmcsa.dot.gov/mehandbook/MEhandbook.aspx

National Registry of Certified Medical Examiners

http://nrcme.fmcsa.dot.gov/

Office of Medical Programs

http://www.fmcsa.dot.gov/regulations/medical

Medical Advisory Criteria Under Evaluation

http://www.fmcsa.dot.gov/regulations/rulemaking

Medical Review Board

http://www.mrb.fmcsa.dot.gov/

Federal Advisory Committee Act

http://www.gsa.gov/portal/content/100916

Frequently Asked Questions (FMCSA)

http://www.fmcsa.dot.gov/rules-regulations/topics/medical/faqs.aspx

Frequently Asked Questions (NRCME)

http://nrcme.fmcsa.dot.gov/documents%5CNational_Registry_FAQ.pdf

Definitions

Administrative Definitions

http://www.fmcsa.dot.gov/rules-regulations/administration/fmcsr/fmcsrruletext.aspx?reg=383.5

Forms

Form 649-F

http://www.fmcsa.dot.gov/documents/forms/649f.pdf

Medical Certificate

http://www.fmcsa.dot.gov/sites/fmcsa.dot.gov/files/docs/Medical_Examiners_Certificate.pdf

Skill Performance Evaluation for Limb Injury or Limitation

http://www.fmcsa.dot.gov/rules-regulations/topics/medical/spepackage.htm

Drug & Alcohol Testing

http://www.dot.gov/business/drug-and-alcohol-testing/dot-rule-49-cfr-part-40-section-403

Vehicle Crash Statistics

Vehicle Crash Statistics

http://www-nrd.nhtsa.dot.gov/Pubs/811552.pdf

Office of Analysis, Research & Technology

http://www.fmcsa.dot.gov/safety/analysis-research-technology

Other Department of Transportation Guides

FAA Aviation Medical Examiner Guidelines

http://www.faa.gov/about/office_org/headquarters_offices/avs/offices/aam/ame/guide/

Federal Transit Administration (Prescription and OTC Medication Guides)

http://www.fta.dot.gov/documents/RxOTC_April2011.pdf

Occupational Safety & Health Administration

OSHA Guide for Trucking Industry

http://www.osha.gov/SLTC/trucking_industry/index.html

Trucking Industry

Health of Truck Drivers on the Road

http://www.truckertrucker.com/article/1952

American Trucking Associations

http://www.trucking.org/

Trucking Industry Defense Association

http://www.tida.org/

Owner-Operator Independent Drivers Association

http://www.ooida.com/

American Association of Owner Operators

http://www.aaofoo.com/

Complete Guide to Medical Examiner Certification

March 25, 2013


Table of Contents Introduction .................................................................................................................................................. 5

The National Registry Overview.................................................................................................................... 5

National Registry Background................................................................................................................... 5

Objectives.............................................................................................................................................. 5

This Guide ............................................................................................................................................. 5

The Certification Test .................................................................................................................................... 5

Test Construction...................................................................................................................................... 6

Test Content.............................................................................................................................................. 6

Test Specifications ................................................................................................................................ 6

Eligibility Requirements ................................................................................................................................ 7

Training ..................................................................................................................................................... 7

Test Application ............................................................................................................................................ 8

Testing Organizations................................................................................................................................ 8

Application Procedures............................................................................................................................. 9

Registration........................................................................................................................................... 9

Taking the FMCSA Medical Examiner Certification Test............................................................................... 9

Scheduling the Test................................................................................................................................... 9

Test Fees ................................................................................................................................................. 10

Test Preparation...................................................................................................................................... 10

Test Taking Tip ........................................................................................................................................ 10

Sample Certification Test Items .............................................................................................................. 10

Resources .................................................................................................................................................... 10

National Registry Website and Listserv .................................................................................................. 10

Resources on the National Registry Website.......................................................................................... 11

Sample Training .................................................................................................................................. 11

Medical Examiner Handbook.............................................................................................................. 11

Information Manual for Training Organizations ................................................................................. 11

Administrative Manual for Testing Organizations .............................................................................. 11

Testing Policies and Procedures ................................................................................................................. 11

The Day of the Test ................................................................................................................................. 11

Security ............................................................................................................................................... 12

Page 2 of 44


At a test center.................................................................................................................................... 12

Online testing...................................................................................................................................... 12

During testing the following apply:..................................................................................................... 12

Timed Test........................................................................................................................................... 13

Misconduct ......................................................................................................................................... 13

Test Procedures ...................................................................................................................................... 13

Candidate Comments and Feedback .................................................................................................. 13

Receiving Test Score/Passing the Test ................................................................................................ 13

Not Passing the Test............................................................................................................................ 14

Confidentiality..................................................................................................................................... 14

Quick Reference Guide ....................................................................................................................... 14

Maintaining Certification ............................................................................................................................ 14

Listing on the National Registry .............................................................................................................. 15

Driver Examination Reports .................................................................................................................... 15

Performance Monitoring ........................................................................................................................ 15

Auditing................................................................................................................................................... 16

Removal from the National Registry........................................................................................................... 16

Reasons for Removal............................................................................................................................... 16

Procedure for Removal ........................................................................................................................... 16

Voluntary Removal.............................................................................................................................. 16

Involuntary Removal: Notice of Proposed Removal .......................................................................... 17

Response to Notice of Proposed Removal and Corrective Action.......................................................... 17

Opposing a Notice of Proposed Removal ........................................................................................... 17

Compliance and Corrective Action ..................................................................................................... 17

Request for an Administrative Review.................................................................................................... 18

Emergency Removal............................................................................................................................ 18

Reinstatement on the National Registry............................................................................................. 18

Effect of Final Decision by FMCSA ...................................................................................................... 18

Appendices.................................................................................................................................................. 19

Appendix A: National Registry of Certified Medical Examiners Medical Examiner Training, Guidance

for the Core Curriculum Specifications ................................................................................................... 19

Appendix B: Detailed Content Outline................................................................................................... 26

Page 3 of 44


Appendix C: Sample FMCSA Medical Examiner Certification Test Items............................................... 35

Appendix D: Quick Reference Guide...................................................................................................... 41

Appendix E: FMCSA Form MCSA-5850, CMV Driver Medical Examination Results............................... 43

Page 4 of 44


Introduction

The National Registry of Certified Medical Examiners (hereinafter referred to as the “National Registry”) was established in accordance with the final rule published by the Federal Motor Carrier Safety Administration (FMCSA) in the Federal Register on April 20, 2012. This rule requires that all medical examiners who conduct physical examinations for interstate commercial motor vehicle (CMV) drivers:

• Maintain a valid State license to conduct medical examinations; • Complete required training on FMCSA’s physical qualification standards; • Pass the FMCSA Medical Examiner Certification Test to demonstrate knowledge of FMCSA’s

physical qualification standards; and • Complete refresher training every 5 years and recertification testing every 10 years.

Beginning May 21, 2014, all medical certificates issued to interstate truck and bus drivers must come from medical examiners listed on the National Registry.

The National Registry Overview

In August 2005, Congress enacted the Safe, Accountable, Flexible, Efficient Transportation Equity Act: A Legacy for Users (SAFETEA-LU), which authorized FMCSA to establish the National Registry of Certified Medical Examiners (49 U.S. Code 31149).

National Registry Background

The National Registry is designed to improve highway safety by producing trained, certified medical examiners who can determine whether a CMV driver meets FMCSA standards and guidelines.

Objectives

The objectives of the National Registry Program are:

• Improve highway safety; • Ensure that medical examiners understand FMCSA medical standards and guidelines and

how they apply to interstate CMV drivers; • Maintain training and testing program for medical examiners; • Promote public confidence in the quality of the medical examiners who certify CMV drivers;

and • Establish an online list of certified medical examiners.

This Guide

This Complete Guide to Medical Examiner Certification is designed to help medical examiners apply and prepare for the FMCSA Medical Examiner Certification Test and can be used as a reference tool after certification. The Guide provides information about eligibility requirements, applying to take the certification test, the certification testing process, and maintaining certification. It also includes information about FMCSA policies and procedures for listing on the National Registry.

The Certification Test

FMCSA modeled the development of the certification test on recognized processes and procedures established by the National Commission for Certifying Agencies (NCCA), a national accreditation body for a variety of certification programs and organizations that assess professional competency. The NCCA uses a peer review process to establish accreditation standards, evaluate compliance with the standards,

Page 5 of 44


recognize organizations and programs that demonstrate compliance, and serve as a resource on quality certification. FMCSA used these standards for certification test development so medical examiners, the drivers they examine, the motor carriers that employ the drivers and the public would have confidence in the qualifications of FMCSA certified medical examiners.

Test Construction

FMCSA performed an extensive role delineation study to identify the critical knowledge, skills, and abilities needed to perform CMV driver physical examinations in accordance with current FMCSA regulations and advisory criteria. A variety of methods were used to complete the study, including an literature review, direct observations of CMV driver physical examinations, a national survey of medical examiners, and medical examiner expert Working Integrated Product Team (WIPT) meetings. The study results provided a blueprint for the FMCSA Medical Examiner Certification Test and the development of core curriculum specifications for the initial medical examiner training that will be provided by private-sector training organizations.

Test Content

Test Specifications

The final test specifications shown in Table 1 reflect the number of items and cognitive level of questions for each content area on the certification test. These specifications were developed combining medical examiner survey results and consensus of WIPT members. This blend of survey results and consensus among medical examiners is superior to using either element alone.

Table 1: Core Content Areas

FMCSA Medical Examiner Certification Test Items

Cognitive Level

Content Area Recall Application Analysis Totals

I. DRIVER’S MEDICAL INFORMATION 23 33 14 70

A. Identification and History 4 6 10 20

B. Physical Examination and Evaluation 8 15 2 25

C. Diagnostic Tests and/or Referrals 6 10 2 18

D. Documentation of Ancillary Information 5 2 0 7

II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION 7 12 11 30

A. Health Education Counseling 2 1 1 4

B. Risk Assessment 2 4 8 14

C. Certification Outcomes and Intervals 3 7 2 12

Totals 30 45 25 100

Page 6 of 44

Eligibility Requirements

To be eligible to take the FMCSA Medical Examiner Certification Test, the medical examiner candidate must:

• Meet the professional requirements established in 49 CFR 390.103(a) (1): Medical Examiner must “be licensed, certified, or registered in accordance with applicable State laws and regulations to perform physical examinations. The applicant must be an advanced practice nurse, doctor of chiropractic, doctor of medicine, doctor of osteopathy, physician assistant, or other medical professional authorized by applicable State laws and regulations to perform physical examinations.”

• Complete required initial medical examiner training on the FMCSA physical qualification standards, guidance and related knowledge for CMV drivers.

Training

Initial medical examiner training must be completed prior to sitting for the FMCSA Medical Examiner Certification Test. The training reviews FMCSA-specific knowledge about CMV drivers and the physical and mental demands of their job. This training is required because specialized knowledge of CMV drivers is not included in healthcare practitioner education and licensure.

Medical examiner training ensures that candidates have baseline instruction in FMCSA’s CMV driver physical qualification standards, medical guidelines, and medical examiner responsibilities. Medical scope of practice is defined by each State. It demonstrates the practitioner’s clinical knowledge. The medical examiner training builds on that clinical knowledge and applies it to the fitness for duty determination for CMV drivers.

FMCSA provides a list of required training topics to private-sector professional associations, health care organizations, and other for-profit and non-profit training providers. A detailed list of training topics can be found in the National Registry of Certified Medical Examiners Medical Examiner Training, Guidance for the Core Curriculum Specifications in Appendix A. Training providers choose the training delivery method, which may include but is not limited to the following: traditional instructor-led classroom instruction; self-paced, computer- or web-based learning; a combination of both; or a guided literature review.

There is no FMCSA requirement for length of training. Training providers are not reimbursed by the Federal government for developing training courses and may charge reasonable fees to those candidates who choose to attend. The training program must meet the following requirements:

• Be conducted by a training provider that is accredited by a nationally-recognized medical profession accrediting organization to provide continuing education units;

• Present course content that addresses the eight topics outlined in the current core curriculum specifications established by FMCSA.

• Provide the medical examiner with proof of training. FMCSA recommends providing medical examiner with a certificate of completion. The training certificate must include the following information:

Medical examiner’s name and professional title. Date training was completed. Training provider name and contact information. Title of training program. Training program accreditation information, including:

Name of accrediting body. Affirmation of accreditation in accordance with the requirements of the accrediting body.


o o o o o

--

Page 7 of 44


- Accrediting body contact information.

NOTE: The medical examiner can attend a training program accredited by any medical profession accrediting organization (i.e. a physician can complete a training program accredited by a nurse practitioner accrediting organization).

Test Application

Testing Organizations

The FMCSA Medical Examiner Certification Test is delivered only by testing organizations that have been approved by FMCSA and listed on the National Registry Website (https://nationalregistry.fmcsa.dot.gov). Approved testing organizations administer only the currently authorized version of the certification test developed and furnished by FMCSA. To accommodate the number of potential medical examiners and their geographic dispersion, the FMCSA Medical Examiner Certification Test is administered by multiple, private-sector, professional testing organizations. In addition, the Agency is permitting testing organizations to offer online monitored testing. Given the variety of testing organizations and methods used, it is important to maintain common standards of test presentation, facilities, data security, and other factors. These standards must be carefully defined and applied so medical examiners have an equal opportunity to demonstrate their knowledge without concern for the reliability or validity of the test and its administration. 49 CFR 390.107 establishes these standards, and states (in part):

(a) The testing organization has documented policies and procedures that: 1. Use secure protocols to access, process, store, and transmit all test items, test forms,

test data, and candidate information and ensure access by authorized personnel only. 2. Ensure testing environments are reasonably comfortable and have minimal

distractions. 3. Prevent to the greatest extent practicable the opportunity for a test taker to attain a

passing score by fraudulent means. 4. Ensure that test center staff that interact with and proctor examinees or provide

technical support have completed formal training, demonstrate competency, and are monitored periodically for quality assurance in testing procedures.

5. Accommodate testing of individuals with disabilities or impairments to minimize the effect of the disabilities or impairments while maintaining the security of the test and data.

(b) Testing organizations that offer testing of examinees at locations that are not operated and staffed by the organization by means of remote, computer-based systems, must, in addition to the requirements of paragraph (a), ensure that such systems:

1. Provide a means to authenticate the identity of the person taking the test. 2. Provide a means for the testing organization to monitor the activity of the person taking

the test 3. Do not allow the person taking the test to reproduce or record the contents of the test by

any means.

(c) The testing organization has submitted its documented policies and procedures as defined in paragraph (a) of this section to FMCSA; and agreed to future reviews by FMCSA to ensure compliance with the criteria listed in this section.

The testing organization administers only the currently authorized version of the FMCSA Medical Examiner Certification Test developed and furnished by FMCSA.

Page 8 of 44

https://nationalregistry.fmcsa.dot.gov/


Application Procedures

Registration

Step 1: Create Your Account

• Create your National Registry Account at https://nationalregistry.fmcsa.dot.gov. • Select “Registration” option. • Enter requisite information. (You must complete registration or your data will not be saved). • Verify all information and submit.

Step 2: Accept Rules of Behavior

The following medical examiner Rules of Behavior will be displayed and must be affirmed and submitted before registration is complete:

• Statement of capability and willingness to comply with the FMCSA requirement to transmit CMV driver examination data to FMCSA electronically once every calendar month.

• Statement agreeing to provide copies of certification of training completion, State license(s), certificate(s), or registration(s) to perform physical examinations, completed Medical Examination Reports, and medical examiner certificates to an authorized representative of FMCSA or to an authorized State or local enforcement agency representative upon request.

• Statement agreeing to accept any written communication from FMCSA relating to participation on the National Registry by electronic mail at the email address(es) provided to FMCSA, including any notice of proposed removal from the National Registry and any such information addressing obligations as a certified medical examiner.

• Statement that all information submitted to FMCSA is true, and accepts the terms. • Statement agreeing to the National Registry/FMCSA Privacy Policy.

Once registration is complete, you will receive a welcome message and a National Registry Number. You will then receive an email with a temporary password and instructions for next steps.

Taking the FMCSA Medical Examiner Certification Test

Scheduling the Test

• Go to https://nationalregistry.fmcsa.dot.gov to find links to testing organizations approved to administer the FMCSA Medical Examiner Certification Test.

• Obtain information about locations and scheduling instructions directly from the testing organizations.

• Schedule a date and time to take the test. Some testing organizations may provide an option to take the test using a secure, remote, computer-based system. If you choose that option, you will need to follow their procedures for making those arrangements.

IMPORTANT: It is your responsibility to keep your contact and licensing information up to date on the National Registry. If your license has expired or your name changes, you MUST put the correct information into the National Registry. Be sure to update the contact (e.g. name, address, etc.) and medical licensing information (e.g. license expires, license number, license state, etc.) you entered when registering on the National Registry website when there are changes. If the contact and medical licensing information you entered during registration on the National Registry website does not match the credentials you present to the test center, you will not be allowed to take the exam.

Page 9 of 44




Test Fees

Although FMCSA reviews the policies and procedures submitted by testing organizations before approving them to provide the test, it does not establish, or regulate the fees established and collected by testing organizations, and does not receive any monies collected by testing organizations or providers.

Testing providers are not reimbursed by the Federal government and may charge fees they deem appropriate for test delivery. The testing provider is responsible for the entire process of fee determination, collection, and refund, if warranted, as well as the advertising of the testing service, determining the testing schedule, and managing applications submitted by candidates taking the certification test.

Test Preparation

As a candidate for the FMCSA Medical Examiner Certification Test, you should review the complete Detailed Content Outline (DCO) in Appendix B to understand the scope and complexity of the test. Test items are limited to the critical tasks specified in the DCO, which identifies the following:

• Task • Cognitive level required to respond to each item • Number of items by major content domain • Number of items by cognitive level

Test Taking Tip

CMV driver medical certification is based on comprehensive physical assessment of driver health. This includes the medical examiner’s informed judgment about the potential impact of a single medical condition or multiple existing medical conditions on the driver’s ability to operate a CMV safely in interstate commerce.

Sample Certification Test Items

Sample test items provide an idea of what to expect on the certification test. Appendix C of this Guide provides several sample test items.

Resources

National Registry Website and Listserv

FMCSA developed the National Registry Website and the National Registry Listserv to disseminate information including the latest National Registry developments and to facilitate communication with the program’s primary stakeholders: medical professionals interested in becoming certified medical examiners; certified medical examiners; industry professionals; CMV drivers; employers; the general public; and all other interested parties.

The National Registry Website (https://nationalregistry.fmcsa.dot.gov) provides information about FMCSA regulations and other requirements relevant to CMV driver physical examinations. The website will include a continually updated list of certified medical examiners that are authorized by FMCSA to perform physical examinations for interstate CMV drivers.

Medical professionals interested in becoming certified medical examiners and being listed on the National Registry can find information about the medical examiner training and certification process on the National Registry Website.

Page 10 of 44

http://nrcme.fmcsa.dot.gov/

http://nrcme.fmcsa.dot.gov/listserv.htm



Resources on the National Registry Website

Sample Training

The Sample Training is a comprehensive example of medical examiner training. This document covers the eight training topics in the core curriculum required by FMCSA. Training providers may modify it to suit whatever delivery methodology they choose.

Medical Examiner Handbook

The Handbook is an online resource that provides information and guidance for medical examiners who perform physical examinations and certifications for interstate CMV drivers.

Information Manual for Training Organizations

This manual is a complete guide to becoming a National Registry training provider. It outlines the requirements, policies, and procedures that apply to training providers.

Administrative Manual for Testing Organizations

This is a single resource to provide testing organizations with the information needed to properly administer the FMCSA Medical Examiner Certification Test. The manual details the requirements, policies, and procedures for validating test takers, test administration, and transmitting results to the National Registry.

Testing Policies and Procedures

The Day of the Test

When you arrive at the testing center, you must provide your National Registry Number, proof of your medical credential, proof of completion of training, and one form of photo identification. At that time, testing center personnel will verify your eligibility to take the test. If eligibility cannot be verified, you will not be allowed to take the test.

The following are acceptable forms of identification:

• U.S. driver’s license with photograph • State ID card with photograph • U.S. passport • U.S. military ID card with photograph • Permanent resident card with photograph • Native American tribal ID Card with photograph • Foreign government-issued passport with photograph • Canadian provincial driver’s license with photograph • Indian and Northern Affairs Canada card with photograph (INAC) • Transportation worker ID with photograph (TWIC)

After your eligibility is verified, the testing proctor will provide instructions on how to proceed. All FMCSA-approved testing organizations have agreed to maintain test administration and security standards. These standards ensure that all candidates have the same opportunity to demonstrate their knowledge and prevent testing irregularities or misconduct.

IMPORTANT: It is your responsibility to keep your contact and licensing information up to date on the National Registry. If your license has expired or your name changes, you MUST put the correct information into the National Registry. Be sure to update the contact (e.g. name, address, etc.) and medical licensing information (e.g. license expires, license number, license state, etc.) you entered when

Page 11 of 44


registering on the National Registry website when there are changes. If the contact and medical licensing information you entered during registration on the National Registry website does not match the credentials you present to the test center, you will not be allowed to take the exam.

Security

Testing organizations approved to deliver the FMCSA Medical Examiner Certification Test have provided FMCSA with their documented policies and procedures for ensuring test security. All tests are monitored to ensure the highest level of security. The testing organization will provide information about their policies and procedures at the time the test is schedule. The following security procedures generally apply during the test:

At a test center

The testing organization must monitor every test session to maintain a standardized environment. This ensures that every medical examiner has an equal opportunity to demonstrate his or her knowledge and protects the integrity of the test. The following security procedures must be enforced by the person (proctor) presenting the test.

• No cameras, notes, documents, audio or video recorders, personal digital assistants (PDAs), pagers, cellular phones or calculators are permitted in the testing area.

• No guests, visitors or family members are allowed in the test room. • Except for keys and wallets, no personal items, including purses, business cases, backpacks,

valuables or weapons may be brought into the test room.

During testing the following apply:

• Eating, drinking and smoking are not permitted inside the test room. • Pencils/markers may be provided and may be available during testing. • Blank scratch paper or dry-erase boards may be provided during testing, and they must be

returned to the proctor at test completion. No documents or notes of any kind may be removed from the testing area.

• The proctor may not answer any questions concerning the test content or requests for interpretations during testing.

• No conversations with others during the test (except with proctors/monitors).

Online testing

The security requirements for online testing are similar to those described for administration at a test center. The testing organization must provide monitoring for every test session to the extent possible. This ensures that every medical examiner has an equal opportunity to demonstrate his or her knowledge and protects the integrity of the test. The following security procedures must be enforced by the testing organization:

• No cameras, notes, documents, audio or video recorders, PDAs, pagers, cellular phones or calculators are permitted within view or reaching distance of the test taker.

• No guests, visitors or family members are allowed in the room. • No conversations with others during the test (except with proctors/monitors). • No personal items such as purses, business cases, and backpacks are allowed within view or

reaching distance of the test taker.

During testing the following apply: • The use of the internet, books, reference materials etc. is not permitted during the exam. • Pencils/markers may be used. • Blank scratch paper may be used. • No conversations with others during the test (except with proctors/monitors). • No telephone communications are permitted • The candidate must remain in the room, seated at the computer within range of the webcam.

Page 12 of 44


Timed Test

The FMCSA Medical Examiner Certification Test is a two hour, timed test. The test contains 120 items; 100 are scored and 20 are being evaluated for inclusion on the test at a future date. Once the actual test begins, the two hour test time runs continuously with no pauses.

Misconduct

Testing centers monitor for misconduct during test administration and have policies and procedures in place for addressing the issue. Generally, candidates who engage in misconduct are dismissed from the testing session and their scores are not reported. Testing organizations will report to FMCSA when any applicant for FMCSA medical examiner certification engages in fraudulent means to pass the FMCSA Medical Examiner Certification Test. FMCSA prohibits the applicant from retaking the test for 90 days.

Examples of misconduct include:

• Creating a disturbance, is abusive or is otherwise uncooperative, and disturbs others in the test room;

• Using electronic communications equipment, such as pagers, cellular phones, or PDAs; • Giving or receiving help or is being suspected of doing so; • Attempting to record test items or makes notes; • Attempting to take the certification test for someone else; • Using notes, books, and other aids; • Talking to a person other than the proctor/monitor while taking the test.

Test Procedures

The computer tracks the time it takes to complete the test. The computer terminates the test when the time limit is reached, regardless of whether the test is completed. Only one test item is presented at a time, and the answers are identified as A, B, C, or D. Each test center will have its own processes that will be explained prior to the exam.

The number of test items answered is reported at test completion. If you have not answered all questions and time remains, you can go back and answer those questions. It is generally best to try to answer all questions. Your score is based on the total number of correct responses.

Candidate Comments and Feedback

Testing Organizations should refrain from collecting comments about the test from candidates taking the test. Once the candidate has completed the test, the proctor should advise them to submit comments directly to FMCSA. The candidate should be advised that submitting a comment does not affect their score.

Receiving Test Score/Passing the Test

The testing organization notifies the candidate that the results will be sent to FMCSA.

After receiving the test answers from the testing center, FMCSA confirms the grading, ensures the validation of the candidate’s credentials and issues a National Registry certificate. The candidate receives official notification via email about his or her certification status. The email includes the medical examiner’s National Registry Number, and information about maintaining certification. Medical examiner’s contact information will then be listed on the National Registry Website.

Page 13 of 44


Not Passing the Test

A medical examiner who does not pass the test for initial certification, recertification, or reinstatement may take it again by submitting another application to a testing organization and paying the appropriate fee. This is retesting. The retest does not have to be performed by the same test provider. The medical examiner must wait 30 days before retaking the test, but there is no limit on the number of times that a medical examiner may take the test. A medical examiner candidate must pass the certification test within 3 years after completing initial training for initial certification or for reinstatement if FMCSA requires the medical examiner candidate to retake the initial training.

If a medical examiner listed on the National Registry fails to pass the certification test prior to the expiration of his or her FMCSA medical examiner certification, FMCSA may issue a notice of proposed removal to the medical examiner. If the medical examiner passes the certification test and meets all the requirements in the notice of proposed removal, FMCSA would issue a new certification. However, if FMCSA has removed the medical examiner from the National Registry, the medical examiner would be required to apply for reinstatement.

Confidentiality

Individual test scores will only be reported to the individual who took the test. Aggregate scores without personally identifiable markers will be used in collaboration with the test consultant to set the passing points for the test and to analyze performance of individual questions.

Information provided to the National Registry may be used for analyses to study certified medical examiners and their practice. Information-sharing will be limited to data reports that are in aggregate form or documents that lack personally identifiable information.

Quick Reference Guide

The Quick Reference Guide to FMCSA Medical Examiner Certification and Listing on the National Registry of Certified Medical Examiners, Appendix D of this Guide, provides a summary of the certification and recertification processes.

Maintaining Certification

To maintain your FMCSA medical examiner certification credential, you must:

• Be licensed, certified, and/or registered, in accordance with applicable State laws and regulations to perform physical examinations in each state in which examinations are performed.

• Complete periodic training as specified by FMCSA every 5 years, and pass the FMCSA Medical Examiner Certification Test every 10 years.

• Agree to provide proof of eligibility upon FMCSA request.

Upon successful recertification, FMCSA will issue a new FMCSA medical examiner certification credential with a new expiration date. You will maintain the National Registry Number assigned to you at your initial certification as long as you remain an FMCSA certified medical examiner.

You may continue to perform CMV driver physical examinations as long as your current certification has not expired. If you have not passed the FMCSA Medical Examiner Certification Test by the expiration of your FMCSA medical examiner certification, then you must cease performing driver exams until passing the certification test again.

To ensure uninterrupted certification, you should complete the training requirement and pass the certification test within 1 year prior to the certification expiration date—definitely no later than the end of the 30-day grace period following your certification expiration date. If you do not complete successful recertification within the 1-year (plus 30-day grace period) timeframe, the following occurs:

Page 14 of 44


• Your certification expires; • Your information remains on the National Registry with a date of removal; and • CMV driver physical examinations performed after certification has expired are not recognized as

valid by FMCSA.

Listing on the National Registry

For initial and continued listing on the National Registry, you must successfully complete all of the requirements for medical examiner certification and recertification defined in this Guide and summarized in the Quick Reference Guide in Appendix D. You must report to FMCSA any changes in application information submitted within 30 days of the change. Additionally, you must comply with the following recordkeeping and reporting requirements.

Driver Examination Reports

Once every calendar month, each medical examiner listed on the National Registry is required to complete and transmit to FMCSA a Form MCSA-5850, CMV Driver Medical Examination Results, with the following information about each CMV driver examined during the previous month:

• Name • Date of birth • Driver’s license number and State • Date of examination • An indication of the examination outcome (for example, medically qualified) • Whether the driver is an intrastate driver only • Whether the driver is a CDL holder • Date of driver medical certification expiration • Any restrictions and variances (for example, wearing corrective lenses or driving within an exempt

intra-city zone)

You must submit this data electronically via a secure FMCSA-designated website. In order to continue to be listed on and to continue participation in the National Registry, you need to comply with this requirement on a monthly basis. If you have not conducted any exams during the month, that must be reported as well. Form MCSA-5850 can be found as Appendix E of this Guide.

Performance Monitoring

Medical examiners must provide Medical Examination Reports and medical examiner’s certificates to an authorized representative, special agent, or investigator of FMCSA or an authorized State or local enforcement agency representative to ensure compliance with FMCSA medical standards and guidelines in performing CMV driver medical examinations. FMCSA monitors medical examiner performance by:

• Conducting periodic reviews of randomly selected medical examiners listed on the National Registry Website to ensure that CMV driver examinations are being conducted properly.

• Periodically reviewing a representative sample of the Medical Examination Reports associated with the name and numerical identifiers of applicants/drivers for errors, omissions, or other indications of improper certification.

To comply with performance monitoring, you must:

• Retain each original (paper or electronic) completed Medical Examination Report and a copy or electronic version of each medical examiner's certificate on file for at least 3 years from the date of the of examination.

Page 15 of 44


• Make all records and information in these files available to an authorized representative of FMCSA or an authorized Federal, State, or local enforcement agency representative, within 48 hours after the request is made for investigations and within 10 days of requests for regular audits.

Auditing

FMCSA will conduct annual medical examiner audits. The purpose of the audit is to check a percentage of medical examiners listed on the National Registry Website to obtain verification of eligibility (e.g., proof of current State medical licensure, registration, or certification to perform physical examinations and proof of completion of required training).

To comply with auditing requirements, you must:

• Maintain documentation of State licensure, registration, or certification to perform physical examinations for each State in which you perform examinations.

• Maintain documentation of completion of all required training.

• Make documentation available to an authorized representative of FMCSA or other authorized representative of Federal, State, or local government within 48 hours of the request for investigations and within 10 days of the request for regular audits of eligibility.

Removal from the National Registry

FMCSA may remove a medical examiner from the National Registry when the medical examiner fails to meet or maintain the qualifications outlined in this Guide, the requirements of other Federal regulations applicable to the medical examiner, or does not meet the requirements of 49 U.S.C. 31149.

Reasons for Removal

The reasons for removal may include, but are not limited to:

• Failure of the medical examiner to comply with the requirements for continued listing on the National Registry as described in this Guide.

• FMCSA discovers that the medical examiner has made errors or omissions or finds other indications of improper certification in either the completed Medical Examination Reports or medical examiner’s certificates.

• FMCSA determines that the medical examiner issued a medical examiner's certificate to an operator of a CMV who failed to meet the applicable standards at the time of the examination.

• Failure of the medical examiner to comply with FMCSA driver examination requirements. • Failure of the medical examiner to complete training in physical and medical examination

standards.

Procedure for Removal

Voluntary Removal

To be removed voluntarily from the National Registry, a medical examiner must submit a request to FMCSA via web account. FMCSA will accept the request and the removal will become effective immediately. However, on and after the date of issuance of a notice of proposed removal from the National Registry, FMCSA will not approve the medical examiner’s request for voluntary removal. A medical examiner requesting voluntary removal should submit a final FMCSA Form MCSA-5850 before the removal takes effect.

Page 16 of 44


Involuntary Removal: Notice of Proposed Removal

FMCSA initiates the process for involuntary removal of a medical examiner from the National Registry by issuing a written notice of proposed removal to the medical examiner, stating the reasons that removal is proposed and any corrective actions necessary for the medical examiner to remain listed on the National Registry.

Response to Notice of Proposed Removal and Corrective Action

A medical examiner who has received a notice of proposed removal must submit any written response to FMCSA via web account no later than 30 days after the date of issuance of the notice of proposed removal. The response must indicate either that the medical examiner believes FMCSA has relied on erroneous reasons, in whole or in part, in proposing removal from the National Registry, or that the medical examiner will comply and take any corrective action specified in the notice of proposed removal.

Opposing a Notice of Proposed Removal

If a medical examiner believes FMCSA to have proposed removal based in whole or in part on an erroneous reason, the medical examiner must explain the situation. FMCSA will review the explanation.

o Withdraw Notice: If FMCSA determines that the reason for proposing removal from the National Registry is an error, FMCSA will withdraw the notice of proposed removal and notify the medical examiner, in writing, of the determination. If FMCSA determines reliance on a partly erroneous reason for proposing removal from the National Registry, FMCSA will modify the notice of proposed removal and notify the medical examiner, in writing, of the determination. The medical examiner must comply and correct the deficiencies identified in the modified notice of proposed removal no later than 60 days after the date FMCSA modifies a notice of proposed removal.

o Affirm Notice: If FMCSA determines there was no reliance on an erroneous reason in proposing removal, FMCSA will affirm the notice of proposed removal and notify the medical examiner, in writing, of the determination. No later than 60 days after the date FMCSA affirms the notice of proposed removal, the medical examiner must comply and correct the deficiencies identified in the notice of proposed removal.

o Removal: If the medical examiner does not submit a written response within 30 days of the date of issuance of a notice of proposed removal, the removal becomes effective, and the medical examiner is immediately removed from the National Registry.

Compliance and Corrective Action

o Compliance: The medical examiner must comply and complete the corrective actions specified in the notice of proposed removal no later than 60 days after either the date of issuance of the notice of proposed removal or the date FMCSA affirms or modifies the notice of proposed removal, whichever is later. The medical examiner must provide documentation of compliance and completion of the corrective actions to FMCSA. FMCSA may conduct any investigations and request any documentation necessary to verify that the medical examiner has complied and completed the required corrective action(s). FMCSA will notify the medical examiner, in writing, whether he or she has met the requirements to continue to be listed on the National Registry.

o Failure to Comply: If the medical examiner fails to complete the proposed corrective action(s) within the 60-day period, the removal becomes effective and the medical examiner is immediately removed from the National Registry. FMCSA will notify the medical examiner, in writing, that he or she has been removed from the National Registry.

Page 17 of 44


o Resolution: At any time before a notice of proposed removal from the National Registry becomes final, the medical examiner who received the notice and FMCSA may resolve the matter by mutual agreement.

Request for an Administrative Review If a medical examiner has been removed from the National Registry, the medical examiner may request an administrative review no later than 30 days after the date the removal becomes effective. The request must be submitted in writing to the FMCSA Associate Administrator for Policy and must explain the error(s) committed in removing the medical examiner from the National Registry, including a list of all factual, legal, and procedural issues in dispute and any supporting information or documents.

o Additional Procedures for an Administrative Review: The Associate Administrator may ask the medical examiner to submit additional data or attend a conference to discuss the removal. If the medical examiner does not provide the information requested, or does not attend the scheduled conference, the Associate Administrator may dismiss the request for administrative review.

o Decision on Administrative Review: The Associate Administrator will complete the administrative review and notify the medical examiner, in writing, of the decision. The decision represents final Agency action. If the Associate Administrator decides the removal was not valid, FMCSA will reinstate the medical examiner and reissue a certification credential to expire on the expiration date of the certificate that was invalidated. The reinstated medical examiner must continue to meet all requirements defined in this Guide.

Emergency Removal

In cases of either willfulness or in which public health, interest, or safety is an issue, the provisions of this section are not applicable and FMCSA may immediately remove a medical examiner from the National Registry and invalidate the FMCSA medical examiner certification credential issued. A medical examiner who has been removed may request an administrative review of that decision.

Reinstatement on the National Registry

A medical examiner who has been removed from the National Registry may apply to FMCSA for reinstatement no sooner than 30 days after the date of removal. The former medical examiner must provide documentation showing compliance with all requirements and completion of any additional corrective actions required in the notice of proposed removal. A medical examiner who has been voluntarily removed may be reinstated by FMCSA after providing documentation showing proof of compliance with all requirements.

Effect of Final Decision by FMCSA

Once removed from the National Registry, the medical examiner’s listing is removed and the FMCSA medical examiner certification credential is no longer valid. The medical examiner’s information remains publicly available for 3 years, with an indication that he/she is no longer listed on the National Registry as of the date of removal.

Page 18 of 44


Appendices

Appendix A: National Registry of Certified Medical Examiners Medical Examiner Training, Guidance for the Core Curriculum Specifications

The guidance for the core curriculum specifications is intended to assist training organizations in developing programs that would be used to fulfill the proposed requirements in the Federal Motor Carrier Safety Administration’s (FMCSA) rule for the National Registry of Certified Medical Examiners (National Registry). The rule states that a medical examiner must complete a training program. FMCSA explained in the preamble to the rule that training providers and organizations must follow the core curriculum specifications in developing training programs for medical examiners who apply for listing on the Agency’s National Registry. This training prepares medical examiners to:

• Apply knowledge of FMCSA’s driver physical qualifications standards and advisory criteria to findings gathered during the driver’s medical examination; and

• Make sound determinations of the driver’s medical and physical qualifications for safely operating a commercial motor vehicle (CMV) in interstate commerce.

The rule, 49 CFR 390.105(b), lists eight topics which must be covered in the core curriculum specifications. The core curriculum specifications are arranged below by numbered topic, followed by guidance to assist training providers in developing programs based on the core curriculum specifications.

Guidance for Each of the Core Curriculum Specifications

(1) Background, rationale, mission and goals of the FMCSA medical examiner’s role in reducing crashes, injuries and fatalities involving commercial motor vehicles.

Mission and Goals of Federal Motor Carrier Safety Administration (FMCSA)

• Discuss the history of FMCSA and its position within the Department of Transportation including its establishment by the Motor Carrier Safety Improvement Act of 1999 and emphasize FMCSA’s Mission to reduce crashes, injuries and fatalities involving large trucks and buses.

Role of the Medical Examiner

• Explain the role of the medical examiner as described in 49 CFR 391.43.

(2) Familiarization with the responsibilities and work environment of commercial motor vehicle (CMV) operations.

The Job of CMV Driving

• Describe the responsibilities, work schedules, physical and emotional demands and lifestyle among CMV drivers and how these vary by the type of driving.

• Discuss factors and job tasks that may be involved in a driver’s performance, such as:

o Loading and unloading trailers; o Inspecting the operating condition of the CMV; and o Work schedules:

− Irregular work, rest, and eating patterns / dietary choices.

Page 19 of 44


(3) Identification of the driver and obtaining, reviewing, and documenting driver medical history, including prescription and over-the-counter medications.

Driver Identification and Medical History:

Discuss the importance of driver identification and review of the following elements of the driver’s medical history as related to the tasks of driving a CMV in interstate commerce.

• Inspect a State-issued identification document with the driver’s photo to verify the identity of the individual being examined; identify the commercial driver’s license or other types of driver’s license.

• Identify, query and note issues in a driver’s medical record and/or health history as available, which may include:

o specific information regarding any affirmative responses in the history; o any illness, surgery, or injury in the last five years; o any other hospitalizations or surgeries; o any recent changes in health status; o whether he/she has any medical conditions or current complaints; o any incidents of disability / physical limitations; o current medications and supplements, and potential side effects, which may be potentially

disqualifying; o his/ her use of recreational/addictive substances (e.g., nicotine, alcohol, inhalants, narcotics

or other habit-forming drugs); o disorders of the eyes (e.g., retinopathy, cataracts, aphakia, glaucoma, macular degeneration,

monocular vision); o disorders of the ears (e.g., hearing loss, hearing aids, vertigo, tinnitus, implants); o cardiac symptoms and disease (e.g., syncope, dyspnea, chest pain, palpitations,

hypertension, congestive heart failure, myocardial infarction, coronary insufficiency, or thrombosis);

o pulmonary symptoms and disease (e.g., dyspnea, orthopnea, chronic cough, asthma, chronic lung disorders, tuberculosis, previous pulmonary embolus, pneumothorax);

o sleep disorders (e.g., obstructive sleep apnea, daytime sleepiness, loud snoring, other); o gastrointestinal disorders (e.g., liver disease, digestive problems, hernias); o genitourinary disorders (e.g., kidney stones and other renal conditions, renal failure, hernias); o diabetes mellitus:

current medications (type, potential side effects, duration on current medication); complications from diabetes; and presence and frequency of hypoglycemic / hyperglycemic episodes/reactions;

o other endocrine disorders (e.g., thyroid disorders, interventions / treatment); o musculoskeletal disorders (e.g., amputations, arthritis, spinal surgery); o neurologic disorders (e.g., loss of consciousness, seizures, stroke / transient ischemic attack,

headaches/ migraines, numbness / weakness) ; or o psychiatric disorders (e.g., schizophrenia, severe depression, anxiety, bipolar disorder, or

other conditions) that could impair a driver’s ability to safely function.

(4) Performing, reviewing and documenting the driver’s medical examination.

Physical Examination (Qualification/Disqualification Standards (§ 391.41 and 391.43))

• Explain the FMCSA physical examination requirements and advisory criteria in relationship to conducting the driver’s physical examination of the following:

o Eyes (§ 391.41(b)(10)) equal reaction of both pupils to light;

Page 20 of 44


evidence of nystagmus and exophthalmos; evaluation of extra-ocular movements.

o Ears (§ 391.41(b)(11)) abnormalities of the ear canal and tympanic membrane; presence of a hearing aid.

o Mouth and throat (§ 391.41(b)(5)) conditions contributing to difficulty swallowing, speaking or breathing;

o Neck (§ 391.41(b)(7)) range of motion; soft tissue palpation / examination (e.g., lymph nodes, thyroid gland).

o Heart (§ 391.41(b)(4)and (b)(6)) chest inspection (e.g., surgical scars, pacemaker / implantable automatic

defibrillator); auscultation for thrills, murmurs, extra sounds, and enlargement; blood pressure and pulse (rate and rhythm); additional signs of disease (e.g., edema, bruits, diaphoresis, distended neck

veins.

o Lungs, chest, and thorax (§ 391.41(b)(5)) respiratory rate and pattern; auscultation for abnormal breath sounds; abnormal chest wall configuration / palpation.

o Abdomen (§ 391.41(a)(3)(i) and 391.43(f)) surgical scars; palpation for enlarged liver or spleen, abnormal masses or bruits / pulsation,

abdominal tenderness, hernias (e.g., inguinal, umbilical, ventral, femoral or other abnormalities).

o Spine (§ 391.41(b)(7)) surgical scars and deformities; tenderness and muscle spasm; loss in range of motion and painful motion; spinal deformities.

o Extremities and trunk (§ 391.41(b)(1), (b)(4) and (b)(7)) gait, mobility, and posture while bearing his/her weight; limping or signs of pain; loss, impairment, or use of orthosis; deformities, atrophy, weakness, paralysis, or surgical scars; elbow and shoulder strength, function, and mobility; handgrip and prehension relative to requirements for controlling a steering wheel

and gear shift; varicosities, skin abnormalities, and cyanosis, clubbing, or edema; leg length discrepancy; lower extremity strength, motion, and function other abnormalities of the trunk.

o Neurologic status (§ 391.41(b)(7), (b)(8) and(b)(9)) impaired equilibrium, coordination or speech pattern (e.g., ataxia); sensory or positional abnormalities; tremor; radicular signs; reflexes (e.g., asymmetric deep-tendon, normal / abnormal patellar and

Babinski). Page 21 of 44


o Mental status (§ 391.41(b)(9)) comprehension and interaction; cognitive impairment; signs of depression, paranoia, antagonism, or aggressiveness that may require

follow-up with a mental health professional.

(5) Performing, obtaining and documenting diagnostic tests and obtaining additional testing or medical opinion from a medical specialist or treating physician.

Diagnostic Testing and Further Evaluation

• Describe the FMCSA diagnostic testing requirements and the medical examiner’s ability to request further testing and evaluation by a specialist.

o Urine test for specific gravity, protein, blood and glucose (§ 391.41(a)(3)(i)); o Whisper or audiometric testing (§ 391.41(b)(11)); o Vision testing for color vision, distant acuity, horizontal field of vision and presence of

monocular vision (§ 391.41(b)(10)); o Other testing as indicated to determine the driver’s medical and physical qualifications for

safely operating a CMV. o Refer to a specialist a driver who exhibits evidence of any of the following disorders (§

391.43(e) and (f)): vision (e.g., retinopathy, macular degeneration); cardiac (e.g., myocardial infarction, coronary insufficiency, blood pressure

control); pulmonary (e.g., emphysema, fibrosis); endocrine (e.g., diabetes); musculoskeletal (e.g., arthritis, neuromuscular disease); neurologic (e.g., seizures); sleep (e.g., obstructive sleep apnea); mental / emotional health (e.g., depression, schizophrenia); or other medical condition(s) that may interfere with ability to safely operate a CMV.

(6) Informing and educating the driver about medications and non-disqualifying medical conditions that require remedial care.

Health Counseling

• Inform course participants of the importance of counseling the driver about:

o possible consequences of non-compliance with a care plan for conditions that have been advised for periodic monitoring with primary healthcare provider;

o possible side effects and interactions of medications (e.g., narcotics, anticoagulants, psychotropics) including products acquired over-the-counter (e.g., antihistamines, cold and cough medications or dietary supplements ) that could negatively affect his/her driving;

o the effect of fatigue, lack of sleep, poor diet, emotional conditions, stress, and other illnesses that can affect safe driving;

o if he/she is a contact lens user, the importance of carrying a pair of glasses while driving; o if he/she uses a hearing aid, the importance of carrying a spare power source for the

device while driving; o if he/she has a history of deep vein thrombosis, the risk associated with inactivity while

driving and interventions that could prevent another thrombotic event; o if he/she has a diabetes exemption, that he/she should:

carry a rapidly absorbable form of glucose while driving;

Page 22 of 44


self-monitor blood glucose one hour before driving and at least once every four hours while driving;

comply with each condition of his/her exemption; plan to submit glucose monitoring logs for each annual recertification;

o corrective or therapeutic steps needed for conditions which may progress and adversely impact safe driving ability (e.g., seek follow-up from primary care physician);

o steps needed for reconsideration of medical certification if driver is certified with a limited interval, e.g., the return date and documentation required for extending the certification time period.

(7) Determining driver certification outcome and period for which certification should be valid.

Assessing the Driver’s Qualifications and Disposition

• Explain how to assess the driver’s medical and physical qualification to operate a CMV safely in interstate commerce using the medical examination findings weighed against the physical and mental demands associated with operating a CMV by:

o Considering a driver’s ability to

move his/her body through space while climbing ladders; bend, stoop, and crouch; enter and exit the cab;

manipulate steering wheel; perform precision prehension and power grasping; use arms, feet, and legs during CMV operation; inspect the operating condition of a tractor and/or trailer; monitor and adjust to a complex driving situation; and consider the adverse health effects of fatigue associated with extended work

hours without breaks;

o Considering identified disease or condition(s) progression rate, stability, and likelihood of gradual or sudden incapacitation for documented conditions (e.g., cardiovascular, neurologic, respiratory, musculoskeletal and other).

Medical Certificate Qualification/Disqualification Decision and Examination Intervals

• Discuss the medical examiner’s obligation to consider potential risk to public safety and the driver’s medical and physical qualifications to drive safely when issuing a medical examiner’s certificate, when to qualify/disqualify the driver and how to determine the expiration date of the certificate by:

o using the requirements stated in the FMCSRs, with nondiscretionary certification standards to disqualify a driver with a history of epilepsy; with diabetes requiring insulin control (unless accompanied by an exemption); when vision parameters (e.g., acuity, horizontal field of vision, color) fall below

minimum standards unless accompanied by an exemption; when hearing measurements with or without a hearing aid fall below minimum

standards; currently taking methadone; with a current clinical diagnosis of alcoholism; or who uses a controlled substance including a narcotic, an amphetamine, or

another habit-forming drug without a prescription from the treating physician;

o using clinical expertise, disqualify a driver when evidence shows a driver has a medical condition that in your opinion will likely interfere with the safe operation of a CMV;

Page 23 of 44


o certifying a driver for an appropriate duration of certification interval; o if he/she has a condition for which the medical examiner is deferring the driver’s medical

certification or disqualifying the driver, informing the driver of the reasons which may include: a vision deficiency (e.g., retinopathy, macular degeneration); the immediate post-operative period; a cardiac event (e.g., myocardial infarction, coronary insufficiency); a chronic pulmonary exacerbation (e.g., emphysema, fibrosis); uncontrolled hypertension; endocrine dysfunctions (e.g., insulin-dependent diabetes); musculoskeletal challenges (e.g., arthritis, neuromuscular disease); a neurologic event (e.g., seizures, stroke, TIA); a sleep disorder (e.g., obstructive sleep apnea); or mental health dysfunctions (e.g., depression, bipolar disorder).

(8) FMCSA reporting and documentation requirements.

Documentation of Medical Examination Findings

Demonstrate the required FMCSA medical examination report forms, appropriate methods for recording the medical examination findings and the rationale for certification decisions including:

• Medical Examination Report Form o identification of the driver; o use of appropriate Medical Examination Report form; o assurance that driver completes and signs driver’s portion of the Medical Examination

Report form; o specifics regarding any affirmative response on the driver’s medical history; o height/weight, blood pressure, pulse; o results of the medical examination, including details of abnormal findings; o audiometric and vision testing results; o presence of a hearing aid and whether it is required to meet the standard; o if obtained, funduscopic examination results; o the need for corrective lenses for driving; o presence or absence of monocular vision and need for a vision exemption; o if driver has diabetes mellitus and is insulin dependent, the need for a diabetes

exemption; o other laboratory, pulmonary, cardiac testing performed; and o the reason(s) for the disqualification and/or referral.

• Other supporting documentation o if driver has current vision exemption, include the ophthalmologist’s or optometrist’s

report; o if a driver has a diabetes exemption, include the endocrinologist’s and

ophthalmologist’s/optometrist’s report; o treating physician’s work release; o if obtained, specialist’s evaluation report; o if the driver has a current Skill Performance Evaluation Certificate, include it; and o results of Substance Abuse Professional evaluations for alcohol and drug use and/or

abuse for a driver with alcoholism who completed counseling and treatment to the point of full recovery.

• Medical Examiner’s Certificate o certification status, which may require:

waiver / exemption; wearing corrective lenses;

Page 24 of 44


wearing a hearing aid; or a Skill Performance Evaluation Certificate;

o complete and accurate documentation on medical certification card including: the examiner’s name, examination date, office address, and telephone number

and Medical Examiner signature; and the driver’s signature.

Page 25 of 44


Appendix B: Detailed Content Outline

Using the Detailed Content Outline

Items on the certification test are limited to what the detailed content outline describes, which should make the outline a useful guide for preparing oneself to take the test. The outline contains several pieces of information about the test. Included in this information are answers to the following questions:

• What competencies can the test cover? • What type of content does the test emphasize? • How complex will test items be?

A review of information from the first page of the outline can help one to understand these points.

The first (of two) major content domains (indicated with a roman numeral I) will cause the test to assess medical examiners’ competencies while they interact with medical information from drivers. Seventy items on the test will assess this type of content. The major domain is subdivided into minor domains (indicated with Arabic letters A, B and so on).

Items covering content in each domain are subdivided among three levels of cognitive complexity. These levels range from simple items based on facts that a medical examiner should have memorized to scenarios describing complicated medical histories. The simple test items focusing on memorized facts are characterized with a label called Recall. The complicated items assessing abilities to solve problems are characterized with a label called Analysis. Between these two types are Application items. These moderately complex items focus on conclusions medical examiners reach about medical information they encounter.

Lastly, by studying each row of the table, a medical examiner will learn that the complexity of assessments of some competencies will be limited. For example, the competency (I.A.2.) in which a medical examiner ensures the driver signs the statement about his or her health history is limited to the recall type of item. Assessment of the competency labeled as I.A.1., which relates to verifying the driver’s identity could involve the recall-type or application-type of item. The competency labeled as 1.A.3.a. could be assessed with items at any of the three levels of cognitive complexity.

Page 26 of 44


Medical examiners are encouraged to study the entire outline so they may understand the nature of the items that could appear on the version of the test that he or she takes. Each version is assembled according to the specifications shown in the outline regarding the number of items from each domain and level of cognition.

National Registry of Certified Medical Examiners (The National Registry) FMCSA Medical Examiner Detailed Content Outline

Open cells show an examination could include items from indicated cognitive levels. Shaded cells prevent appearance of items on examinations.

Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

I. DRIVER’S MEDICAL INFORMATION

4 6 10 20

23 33 14 70

A. Identification and History 1. Verify the identity of the driver 2. Ensure the driver signs the driver’s statement about health history 3. Identify, query, and note issues in a driver’s medical record and / or health history

as available, which may include a. specifics regarding any affirmative responses in the history b. any illness, surgery, or injury in the last five years c. any other hospitalizations or surgeries d. any recent changes in health status e. whether he / she has any medical conditions or current complaints f. any incidents of disability / physical limitations

g. limitations placed during prior FMCSA exams h. current OTC and prescription medications and supplements, and potential

side effects, which may be potentially disqualifying i. his or her use of recreational / addictive substances (e.g., nicotine, alcohol,

inhalants) j. weight disorders (e.g., unexplained loss or gain, obesity)

k. disorders of the eyes (e.g., retinopathy, cataracts, aphakia, glaucoma, macular degeneration, monocular vision)

l. disorders of the ears (e.g., hearing loss, hearing aids, vertigo, Meniere’s, tinnitus, implants)

m. cardiac symptoms (e.g., syncope, dyspnea, chest pain, palpitations) n. cardiovascular diseases (e.g., hypertension, congestive heart failure,

myocardial infarction, coronary insufficiency, or thrombosis) o. hematologic disorders (e.g., bleeding disorders, anemia, cancer, organ

transplant history) p. pulmonary symptoms (e.g., dyspnea, orthopnea, chronic cough) q. pulmonary diseases (e.g., asthma, chronic lung disorders, tuberculosis,

previous pulmonary embolus, pneumothorax) r. sleep disorders (e.g., sleep apnea, narcolepsy, insomnia, daytime

sleepiness, loud snoring, testing and / or treatments) s. gastrointestinal disorders (e.g., pancreatitis, ulcers, ulcerative colitis,

cirrhosis, hepatitis, irritable bowel syndrome, hernias)

Page 27 of 44




Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

t. genitourinary disorders (e.g., polycystic, nephrotic syndrome, kidney stones, renal failure, hernias)

u. diabetes mellitus weight loss duration on current medications medication side effects complications from diabetes availability of emergency glucose supply presence and frequency of hypoglycemic / hyperglycemic episodes /

reactions v. other endocrine disorders (e.g., thyroid disorders, interventions / treatment) w. musculoskeletal disorders (e.g., amputations, arthritis, spinal surgery) x. neoplastic disorders (e.g., leukemia; brain, bone, breast, and lung cancer) y. substance use and abuse (e.g., alcohol, narcotics, illicit or legal drugs) z. neurologic disorders (e.g., loss of consciousness, seizures, stroke / TIA,

headaches / migraines, numbness / weakness) aa. psychiatric disorders (e.g., schizophrenia, depression, anxiety, bipolar,

ADHD, interventions / treatment) bb. other conditions that could impair a driver’s ability to safely function

B. Physical Examination and Evaluation 8 15 2 25 1. Ensure the driver is properly clothed for the physical examination 2. Record height and weight, and note whether a driver is overweight or

underweight 3. Examine the driver’s eyes and note

a. distant acuity in each and both eyes (Snellen comparable values) b. whether corrective lenses are required to meet the standard c. horizontal field of vision in each eye d. color recognition e. presence or absence of monocular vision f. reactivity to light and pupillary equality

g. evidence of nystagmus and exophthalmos h. evaluation of extraoccular movements i. fundoscopic examination results

4. Examine the driver’s ears and note a. abnormalities of the ear canal and tympanic membrane b. whisper test and / or audiometric results (in ANSI standard units) as

indicated c. presence or absence of a hearing aid and whether required to meet the

standard 5. Examine the driver’s mouth and throat, and note conditions that may interfere

with breathing, speaking, or swallowing

Page 28 of 44




Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

6. Examine the driver’s neck and note a. range of motion b. soft tissue palpation / examination (e.g., lymph nodes, thyroid gland)

7. Examine the driver’s heart a. chest inspection (e.g., surgical scars, pacemaker / IAD) b. thrills, murmurs, extra sounds, and enlargement c. blood pressure and pulse (rate and rhythm) d. additional signs of disease (e.g., edema, bruits, diaphoresis, distended neck

veins) 8. Examine the driver’s lungs, chest, and thorax, excluding breasts, and note

a. respiratory rate and pattern b. abnormal breath sounds c. abnormal chest wall configuration / palpation d. scars

9. Examine the driver’s abdomen, and note a. surgical scars b. an enlarged liver or spleen c. abnormal masses or bruits / pulsation d. abdominal tenderness e. hernias (e.g., inguinal, umbilical, ventral, femoral)

10. Examine the driver’s spine and note a. surgical scars and deformities b. tenderness and muscle spasm c. loss in range of motion and painful motion d. kyphosis, scoliosis, or other spinal deformities

11. Examine the driver’s extremities and note a. gait, mobility, and posture while bearing his or her weight; limping or signs of

pain b. loss, impairment, or use of orthosis c. deformities, atrophy, weakness, paralysis, surgical scars, d. elbow and shoulder strength, function, and mobility e. handgrip and prehension relative to requirements for controlling a steering

wheel and gear shift f. varicosities, skin abnormalities, and cyanosis, clubbing, or edema

g. leg length discrepancy; lower extremity strength, motion, and function 12. Examine the driver’s neurologic status and note

a. impaired equilibrium, coordination or speech pattern (e.g., Romberg, finger to nose test)

b. gait disorders c. sensory or positional abnormalities

Page 29 of 44




Cognitive Level

Items

Recall

Ap

plicatio

n

An

alysis

To

tals

f. reflexes (e.g., asymmetric deep-tendon, normal / abnormal patellar and Babinski

d. tremor e. radicular signs

13. Test the driver’s urine and note specific gravity, protein, blood, and glucose 14. Examine the driver’s mental status and note

a. comprehension and interaction b. cognitive impairment (e.g., orientation, intellect, memory, obsessions,

circumstantial / tangential speech) c. signs of depression, paranoia, antagonism, or aggressiveness that may

b. cardiovascular studies (e.g., electrocardiogram, stress test, ejection fraction, vascular studies)

require follow-up with a mental health professional C. Diagnostic Tests and / or Referrals

1. Obtain additional information when indicated by a. audiometrics

6 10 2 18

c. blood analyses (e.g., creatinine, electrolytes, toxicology, lipids, blood chemistries)

d. chest radiograph

f. sleep studies

e. respiratory tests (e.g., spirometry, diffusion, lung volumes, oximetry or arterial blood gas analysis with or without exercise)

g. drug level monitoring (e.g., digoxin, theophylline)

2. Refer a driver who exhibits evidence of any of the following disorders for follow-up care and evaluation by an appropriate specialist or primary care provider

h. other tests

vision (e.g., retinopathy, macular degeneration) cardiac (e.g., myocardial infarction, coronary insufficiency, blood pressure

control) pulmonary (e.g., emphysema, fibrosis) endocrine (e.g., diabetes) musculoskeletal (e.g., arthritis, neuromuscular disease) neurologic (e.g., seizures) sleep (e.g., obstructive sleep apnea) mental / emotional health (e.g., depression, schizophrenia)

a. with limitations in extremity movement for an on-road performance evaluation and / or skill performance evaluation

b. for conditions not directly related to certification, but detected during the examination

3. Refer a driver

Page 30 of 44




Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

D. Documentation of Ancillary Information 5 2 0 7 1. Record / include results as available with other information about the driver,

which may include a. audiometrics b. cardiovascular studies (e.g., electrocardiogram, stress test, ejection fraction,

vascular studies) c. blood analyses (e.g., creatinine, electrolytes, toxicology, lipids, blood

chemistries) d. chest radiograph e. respiratory tests (e.g., spirometry, diffusion, lung volumes, oximetry or

arterial blood gas analysis with or without exercise) f. sleep studies

g. drug level monitoring (e.g., digoxin, theophylline) h. other tests i. treating physician’s work release

2. Integrate a specialist’s evaluation with other information about the driver 3. For a driver who was qualified under a vision exemption, include an annual

ophthalmologist’s or optometrist’s report 4. For a driver who is qualified under a diabetes exemption, include an

endocrinologist’s and ophthalmologist’s / optometrist’s report as required 5. Include if available

a. a current skill performance evaluation certificate b. documentation of intra-city zone exemption

6. Review results of SAP evaluations for alcohol and drug use and / or abuse for a driver with a. alcoholism who completed counseling and treatment to the point of full

recovery b. prohibited drug use who shows evidence he or she is now free from such

use

II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION 7 12 11 30

A. Health Education Counseling 2 1 1 4 1. Explain to a driver consequences of non-compliance with a care plan for

conditions that have been advised for periodic monitoring with primary healthcare provider

2. Advise a driver a. regarding side effects and interactions of medications and supplements

(e.g., narcotics, anticoagulants, psychotropics) including those acquired over the counter (e.g., antihistamines, cold and cough medications) that could negatively affect his or her driving

Page 31 of 44




Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

b. that fatigue, lack of sleep, undesirable diet, emotional conditions, stress, and other illnesses can affect safe driving

c. with contact lenses he or she should carry a pair of glasses while driving

d. with a hearing aid he / she should possess a spare power source for the device while driving

e. who has had a deep vein thrombosis event of risks associated with inactivity while driving and interventions that could prevent another thrombotic event

f. who has diabetes about glucose monitoring frequencies and the minimum threshold while driving

g. with a diabetes exemption, he / she should 1) possess a rapidly absorbable form of glucose while driving 2) self-monitor blood glucose one hour before driving and at least once

every four hours while driving 3) comply with each condition of his / her exemption 4) plan to submit glucose monitoring logs for each annual recertification

3. Inform the driver of the rationale for delaying or potentially disqualifying certification, which may include the immediate post-operative period after certain procedures a vision impairment (e.g., retinopathy, macular degeneration) a cardiac event (e.g., myocardial infarction, coronary insufficiency) a chronic pulmonary exacerbation (e.g., emphysema, fibrosis) uncontrolled hypertension endocrine dysfunction (e.g., diabetes) musculoskeletal challenges (e.g., arthritis, neuromuscular disease) a neurologic event (e.g., seizures, stroke, TIA) a sleep disorder (e.g., obstructive sleep apnea) mental health dysfunctions (e.g., depression, bipolar) postoperative complication

B. Risk Assessment 2 4 8 14 1. Consider a driver’s ability to

couple and uncouple trailers from a tractor load or unload several thousand pounds of freight install and remove tire chains manipulate and secure tarpaulins that cover open trailer move one’s own body through space while climbing ladders; bending,

stooping, and crouching; entering and exiting the cab manipulate an oversized steering wheel shift through several gears using a manual transmission perform precision prehension and power grasping use arms, feet, and legs during CMV operation

Page 32 of 44




Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

2. Review Skill Performance Evaluation (SPE) cases a. identify terms, conditions, and limitations set forth in a driver’s SPE

Certificate b. For a driver who lost a foot, leg, hand, or arm, ensure that an appropriate

SPE Certificate from the FMCSA Division Administrator has been granted 3. Consider a driver’s cognitive ability to

plan a travel route inspect the operating condition of a tractor and / or trailer monitor and adjust to a complex driving situation maneuver through crowded areas quickly alter the course of vehicle to avoid trouble

4. Consider general health and wellness factors such as a. adverse health effects associated with rotating work schedules and irregular

sleep patterns b. long-term effects of fatigue associated with extended work hours without

breaks c. risk factors associated with poor dietary choices d. stressors likely to be associated with extended time away from a driver’s

social support system e. short- and long-term health effects of stress from tight pickup and delivery schedules irregular work, rest, and eating patterns / dietary choices adverse road, weather, and traffic conditions exposure to temperature extremes, vibration, and noise transporting passengers or hazardous products

5. Integrate FMCSA medical advisory criteria and guidelines regarding a driver’s condition into the risk assessment

6. Consider the rate of progression, degree of control, and likelihood of sudden incapacitation (e.g., cardiovascular, neurologic, respiratory, musculoskeletal) for documented conditions

7. Support the rationale for using FMCSA guidelines that have not been published in regulations yet

C. Certification Outcomes and Intervals 3 7 2 12 1. As appropriate, certification standards to disqualify a driver

a. with a history of epilepsy or other seizure history b. with insulin-treated diabetes mellitus (unless accompanied by an exemption) c. when vision parameters (e.g., acuity, horizontal field of vision, color) fall

below minimum standards unless accompanied by an exemption d. when hearing measurements with or without a hearing aid fall below

minimum standards 2. Disqualify a driver who

a. is currently taking methadone

Page 33 of 44




Items Cognitive

Level

Recall

Ap

plicatio

n

An

alysis

To

tals

b. has a current clinical diagnosis of alcoholism c. uses a controlled substance including a narcotic, an amphetamine, or

another habit-forming drug without a prescription from the treating physician, or as appropriate

3. Disqualify a driver when evidence shows a condition or treatment that will likely interfere with the safe operation of a CMV, which may include appropriate supporting documents such as test reports, specialist reports etc.

4. Document the reason(s) for the disqualification and / or referral 5. Advise a driver of the reasons for a disqualification decision and what a driver

could do to become qualified 6. Certify a driver for an appropriate interval 7. Indicate certification status, which may require waiver / exemption, which the Medical Examiner identifies wearing corrective lenses wearing a hearing aid a Skill Performance Evaluation Certificate

8. For a driver that is certified with a limited interval, advise them to return for recertification with the appropriate documentation for his or her condition

9. Complete a medical examination report and medical certificate/card ensure use of currently required examination form ensure the form includes the examiner’s name, examination date, office

address, and telephone number ensure the driver signs the medical certificate/card

Totals 30 45 25 100

Page 34 of 44


Appendix C: Sample FMCSA Medical Examiner Certification Test Items

Sample Item 1: This item will be testing Detailed Content Outline (DCO) task IB3f (cognitive level: recall):

I. DRIVER’S MEDICAL INFORMATION B. Physical Examination and Evaluation

3. Examine the driver’s eyes and note f. reactivity to light and pupillary equality

According to FMCSA regulations, which of the following must the medical examiner evaluate when examining a driver's eyes?

A. Pupil reactivity B. Iris symmetry C. Conjunctival injection D. Corneal thickness

Correct Response:

A. Pupil reactivity This is the correct response because it is the only option that is included on the Medical Examination Report Form for physical examination of the eyes. This is a cranial nerve test. A positive finding indicates a significant neurological problem that must be worked up or have an explanation that clarifies whether or not the driver has a condition that may interfere with the ability to safely operate a CMV.

Incorrect Responses:

B. Iris symmetry This is incorrect because determining iris symmetry is not required by FMCSA.

C. Conjunctival injection This is incorrect because most causes of conjunctival injection would not be disqualifying. Causes that are suspicious for a disqualifying condition need additional evaluation. While this abnormal finding should be explained, with determination of possible effects on safe driving before making a certification decision, it is not a condition that is specified in FMCSA regulations.

D. Corneal thickness This is incorrect because it is not measured in an office examination except by an eye specialist.

Page 35 of 44


Sample Item 2: This item will be testing DCO task IIC6 (cognitive level: recall): II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION

C. Certification Outcomes and Intervals 6. Certify a driver for an appropriate interval

According to FMCSA regulations, medical qualification for two years can be given to a driver who has

A. An SPE certificate for a left below the knee amputation (BKA). B. Hypertension. C. A recent diagnosis of Lewy body dementia. D. Documented medical marijuana use for pain control.

Correct: A. An SPE certificate for a left below the knee amputation. This is the correct response because in order to obtain the SPE certificate, the driver had to demonstrate the ability to perform all tasks for the commercial driver job description.


B. Hypertension. This is not the correct response because drivers with hypertension are only given a medical certificate that is good for one year.

C. A recent diagnosis of Lewy body dementia. This is not the correct response because this is a progressive, degenerative condition with no known treatment. The effects of Lewy body dementia impact the ability to operate a CMV safely.

D. Documented medical marijuana use for pain control This is not the correct response because marijuana remains a drug listed in Schedule I of the Controlled Substances Act. It remains unacceptable for any safety sensitive employee subject to drug testing under the drug testing regulations of DOT to use marijuana. Also, FMCSA medical guidelines state that “driving impairment due to marijuana use is well substantiated.”

Page 36 of 44


Sample Item 3: This item will be testing DCO task IB11e (cognitive level: application): I. DRIVER’S MEDICAL INFORMATION

B. Physical Examination and Evaluation 11. Examine the driver’s extremities and note

e. handgrip and prehension relative to requirements for controlling a steering wheel and gear shift

During his visit to the medical examiner, a driver complains of severe pain in his finger for the last two weeks after it was punctured. The examination reveals an infected, swollen finger. After the medical examiner inquires, the driver states that the pain is made worse when he grips the steering wheel. Which of the following should the medical examiner do next?

A. Obtain a hand X-ray. B. Assess capillary refill in the hand. C. Obtain a culture and sensitivity. D. Assess the driver's grip strength.

Correct: D. Assess the driver’s grip strength. This is the correct response because the condition does not present a safety risk unless it interferes with the ability of the driver to hold and control the steering wheel.


A. Obtain a hand X-ray. This is not the correct response because this is a diagnostic test that a healthcare provider or specialist would perform or order. Your role as a medical examiner is to determine if the condition interferes with the ability of the driver to safely operate a CMV.

B. Assess capillary refill in the hand. This is not the correct response because given the information in the question it is not the primary consideration for determining if the driver can safely operate a CMV.

C. Obtain a culture and sensitivity. This is not the correct response because this is an action that a treating healthcare provider or specialist would do in the course workup and treatment. Your role as a medical examiner is to determine if the condition interferes with the ability of the driver to safely operate a CMV.

Page 37 of 44


Sample Item 4: This item will be testing DCO task IIC8 (cognitive level: application): II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION

C. Certification Outcomes and Intervals 8. Advise a driver certified with a limited interval to return for recertification with

the appropriate documentation for his or her condition

A new driver who had a myocardial infarction six months ago is certified after completing an acceptable exercise tolerance test and is cleared by a cardiologist. According to FMCSA guidelines, which of the following is recommended regarding recertification and exercise tolerance test monitoring intervals?

Recertification Exercise tolerance

A. Every year Every year B. Every two years Every year C. Every year Every two years D. Every two years Every two years

Correct: C. every year; every two years This is the correct response because according to FMCSA medical guidelines, when a myocardial infarction is part of the medical history, there is a significant increased risk for another myocardial infarction to occur within six months to a year; therefore, a maximum of one year certification is the guideline. Myocardial infarction guidelines also recommend exercise tolerance testing at least every two years to demonstrate continued ability to safely operate a CMV.


A. every year; every year This is not the correct response because the FMCSA medical guidance is to obtain an exercise tolerance test every two years. In this question, there is nothing to indicate that more frequent testing is necessary.

B. every two years; every year This is not the correct response because it reverses the guidelines. Even if you do not recall the recommendation, logically, one would eliminate this option because having the driver obtain a test every year and then waiting for up to a year to review the test results is not reasonable when unacceptable test results indicate the driver may not be able to safely operate a CMV.

D. every two years; every two years This is not the correct response because the guideline is to recertify every year. Even if you do not recall the actual guideline, one would logically eliminate this option because this is the maximum recertification period for a driver who meets all qualification requirements. It is appropriate that a driver at increased risk for an incapacitating cardiac event should be monitored more frequently.

Page 38 of 44


Sample Item 5: This item will be testing DCO task IA3a (cognitive level: analysis): I. DRIVER’S MEDICAL INFORMATION

A. Identification and History 3. Identify, query, and note issues in a driver’s medical record and / or health

history as available, which may include a. specifics regarding any affirmative responses in the history

A 46-year-old male driver presents for recertification. He has a history of chronic gastro esophageal reflux disease (GERD). He takes esomeprazole (Nexium) and over-the-counter cimetidine (Tagamet). He states that he feels fine, but has trouble finding foods that do not trigger his GERD when he is on the road. Which of the following should the medical examiner do first?

A. Disqualify the driver until he has a nutritional consultation. B. Certify the driver and advise him to carry non-triggering foods in a cooler. C. Contact the driver's physician and request an upper GI study. D. Correlate the GI history findings with the abdominal examination.

Correct: D. Correlate the GI history findings with the abdominal examination. This is the correct response because given the information in the question; a medical examiner would need to examine the driver before having sufficient information about the health of the driver to consider any of the other options.


A. Disqualify the driver until he has a nutritional consultation. This is not the correct response because until completion of the examination, there is insufficient information to make a certification decision. In addition, there is no regulation or medical guideline that requires a nutritional consultation in order to be certified.

B. Certify the driver and advise him to carry non-triggering foods in a cooler. This is not the correct response because until completion of the examination, there is insufficient information to make a certification decision.

C. Contact the driver’s primary care provider and request an upper-GI study. This is not the correct response because until completion of the examination, one does not have sufficient information to make a referral decision.

Page 39 of 44


Sample Item 6: This item will be testing DCO task IIC3 (cognitive level: analysis): II. DETERMINATION OF DRIVER’S QUALIFICATIONS AND DISPOSITION

C. Certification Outcomes and Intervals 3. Disqualify a driver when evidence shows a condition exists that will likely

interfere with the safe operation of a CMV, which may include sufficient supporting opinions and information from specialists

A 25-year-old female driver denies a history of any medical problems. She is a nonsmoker who exercises regularly without symptoms. The medical examiner auscultates bilateral wheezes during the examination. The driver's SpO2 is 90 percent in the medical examiner's office. The rest of the examination is normal. The driver should be

A. Temporarily disqualified pending results of a cardiac workup. B. Qualified since she has no cardiac symptoms. C. Temporarily disqualified until further evaluation. D. Qualified because her O2 saturation exceeds the minimum.

Correct: C. Temporarily disqualified until further evaluation. This is the correct response because the driver has a non-diagnosed respiratory or thoracic illness that might interfere with the ability to safely operate a CMV. The driver should not be certified until the etiology is confirmed and treatment has been shown to be effective, safe, and stable. Also, according to FMCSA medical guidelines, a SpO2 of less than 92 percent warrants obtaining an arterial blood gas analysis.


A. Temporarily disqualified pending results of a cardiac workup. This is not the correct response because while it is correct that the driver should not be certified, there is nothing in the question data that indicates evaluation should be limited to the heart.

B. Qualified since she has no cardiac symptoms. This is not the correct response because the information in the question does not provide sufficient data to rule out the presence of a disqualifying cardiac or other thoracic problem.

D. Qualified because her O2 saturation exceeds the minimum. This is not the correct response because according to FMCSA guidelines, a SpO2 of less than 92 percent warrants obtaining an arterial blood gas analysis.

Page 40 of 44


Appendix D: Quick Reference Guide Federal Motor Carrier Safety Administration (FMCSA) Medical Examiner Certification and Listing on the National Registry of Certified Medical Examiners

Follow these steps to be an FMCSA certified medical examiner.

Certification

Registration

Step 1: Create Your Account

• Go to https://nationalregistry.fmcsa.dot.gov to create your National Registry Account. • Select “Registration” option. • Enter required information. (Complete registration or data will not be saved.) • Confirm all information as true and submit entries. • Accept Rules of Behavior and submit. • Receive Welcome Message and National Registry Number. • Receive email with temporary password and instructions.

Training

Step 2: Complete Required Training

• Go to https://nationalregistry.fmcsa.dot.gov to find a list of training providers. • Complete a training program that:

o Is conducted by a training provider that is accredited by a nationally recognized medical profession accrediting organization to provide continuing education units.

o Provides training participants with proof of participation. o Provides FMCSA point of contact information to training participants. o Covers the current core curriculum specifications established by FMCSA for medical

examiner training.

Certification Testing

Step 3: Take the FMCSA Medical Examiner Certification Test

• Go to https://nationalregistry.fmcsa.dot.gov to search for a list of testing organizations approved to administer the FMCSA Medical Examiner Certification Test.

• Obtain information about locations and scheduling instructions directly from the testing organizations.

• Schedule the test. Some testing organizations may provide an option to take the test using a secure, remote, computer-based system.

• Provide your National Registry Number, proof of current medical licensure, proof of completion of training, and one form of photo identification when arriving at the test center.

• Take and pass the FMCSA Medical Examiner Certification Test.

Page 41 of 44





Recertification (required every 10 years)

Training Step 1: Complete Periodic Training • Complete periodic training as specified by FMCSA every 5 years. • Go to https://nationalregistry.fmcsa.dot.gov for information about how to access and complete

periodic training.

Certification Testing Step 2: Take the FMCSA Medical Examiner Certification Test • Go to https://nationalregistry.fmcsa.dot.gov to:

o Apply for recertification. o Accept Rules of Behavior and submit. o Find links to testing organizations approved to administer the FMCSA Medical Examiner

Certification Test. • Obtain information about locations and scheduling instructions directly from the testing

organizations. • Schedule the test. • Provide your National Registry Number, proof of your medical credential, proof of completion of

training, and one form of photo identification when arriving at the test center to take the test. • Take and pass the FMCSA Medical Examiner Certification Test.

Continued Listing on the National Registry

To continue listing on the National Registry of Certified Medical Examiners, you must comply with the following requirements.

General Requirements • Report to FMCSA any changes in the application information within 30 days of the change. • Continue to be licensed, certified, or registered, and authorized to perform physical examinations,

in accordance with the applicable laws and regulations of each State in which you perform driver examinations.

• Maintain documentation of State licensure, registration, or certification to perform physical examinations for each State in which you perform examinations and documentation of completion of all required training. You must make this documentation available to an authorized representative of FMCSA or an authorized representative of Federal, State, or local government upon request.

Periodic Training • Complete periodic training as specified by FMCSA every 5 years.

Recertification • Complete recertification by taking and passing the FMCSA Medical Examiner Certification Test

every 10 years. (Note: FMCSA will issue a new medical examiner certification credential valid for 10 years when you successfully complete the required training and testing).

Submission of Monthly Reports/Commercial Motor Vehicle Driver Medical Examination Results • Once every calendar month, you must electronically transmit to the Director of Medical Programs,

via a secure FMCSA-designated Website, a completed Form MCSA-5850, Medical Examiner Submission of CMV Driver Medical Examination Results.

• The Form must include all information specified for each medical examination conducted during the previous month for any driver who is required to be examined by a medical examiner listed on the National Registry of Certified Medical Examiners.

Page 42 of 44




Appendix E: FMCSA Form MCSA-5850, CMV Driver Medical Examination Results

CMV Driver Medical Examination Results Form U.S. Department of Transportation

Federal Motor Carrier Safety Administration OMB Control Number: 2126-0006 Expiration Date: July 31, 2015

Assigned FMCSA Form Number: MCSA-5850Public Burden Statement:

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 5 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

You are required to submit the following driver medical examination data every month. Complete this form for each driver medical examination concluded.

Page 43 of 44


National Registry of Certified Medical Examiners Privacy Act StatementThis statement is provided pursuant to the Privacy Act of 1974, 5 USC § 552a. The information on the attached Form MCSA-5850 CMV Driver Examination Results is solicited under the authority of Title 49, United States Code (U.S.C.) §§ 40113, 44702, 44703, 44709 and 14 C.F.R. Part 6-7.

With limited exceptions, all drivers who operate commercial motor vehicles (CMVs), as defined in 49 CFR 390.5, in interstate commerce must comply with the qualification requirements of part 391 (§ 391.1). Each driver subject to the physical qualification requirements must be examined and certified by a medical examiner, as defined in § 390.5, at least once every 2 years. For certain drivers, such as those with severe cases of hypertension or other acute medical conditions, more frequent medical re-examination by a medical examiner may be required to determine whether the driver can still be certified.

Medical examiners are required to submit data every month for each driver physical examination conducted. Driver or medical examiner social security number is not required. Incomplete submission may result in removal of a medical examiner from the National Registry Program. The purpose of information is to record results of a driver’s physical qualification to operate a CMV in interstate commerce according to the requirement in 49 CFR 391.41-49.

The information will be used to provide data for FMCSA’s automated National Registry Data System. The information will become part of an FMCSA Privacy Act system of record. These records and information in these records will be collected and used to link a specific medical examiner to specific driver medical examination outcome data.

The written consent authorization of this form under OMB Control Number: 2126-0006 permits FMCSA to request driver physical examination outcome data from medical examiners.

Page 44 of 44

Medical Examination ReportFOR COMMERCIAL DRIVER FITNESS DETERMINATION

649-F (6045)

1. DRIVER'S INFORMATION Driver completes this section

Date of Exam M Recertification

M / D / Y

Driver's Name (Last, First, Middle) Social Security No. Birthdate Age Sex New Certification

F Follow-up

Address City, State, Zip Code Work Tel: ( ) Driver License No. License Class State of Issue A C B DHome Tel: ( )

Other

HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver. 2.

Yes No Yes No Yes No Lung disease, emphysema, asthma, chronic bronchitis Fainting, dizziness

Any illness or injury in the last 5 years? Kidney disease, dialysis Sleep disorders, pauses in breathingHead/Brain injuries, disorders or illnesses Liver disease while asleep, daytime sleepiness, loudSeizures, epilepsy snoringDigestive problems

medication_______________________________ Diabetes or elevated blood sugar controlled by:

Stroke or paralysisEye disorders or impaired vision (except corrective lenses) diet Missing or impaired hand, arm, foot, leg,Ear disorders, loss of hearing or balance pills finger, toe Heart disease or heart attack; other cardiovascular condition insulin Spinal injury or disease

medication_______________________________ Nervous or psychiatric disorders, e.g., severe depression medication____________________ Chronic low back pain

Heart surgery (valve replacement/bypass, angioplasty, pacemaker) Regular, frequent alcohol useLoss of, or altered consciousnessHigh blood pressure medication___________________ Narcotic or habit forming drug useMuscular disease Shortness of breath

For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate.

Driver's Signature Date

Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of medications, including over-the-counter medications, while driving. This discussion must be documented below. )

179

TESTING (Medical Examiner completes Section 3 through 7) Name: Last, First, Middle,

3. VISION Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.

INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.

Numerical readings must be provided. Applicant can recognize and distinguish among traffic control Yes

HORIZONTAL FIELD OF VISIONACUITYACUITY UNCORRECTEDUNCORRECTED CORRECTEDCORRECTED

Right EyeRight EyeRight EyeRight Eye 20/20/ 20/20/

Left EyeLeft Eye 20/20/ 20/20/ Left EyeLeft Eye

Both EyesBoth Eyes 20/20/ 20/20/

signals and devices showing standard red, green, and amber colors ? No

Applicant meets visual acuity requirement only when wearing: Corrective Lenses

Monocular Vision: Yes No

Complete next line only if vision testing is done by an opthalmologist or optometrist

Date of Examination Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature

4. HEARING Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB Check if hearing aid used for tests. Check if hearing aid required to meet standard.

INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3.

Numerical readings must be recorded. Right Ear Left Ear

a) Record distance from individual at which Right ear Left Ear b) If audiometer is used, record hearing loss in 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz forced whispered voice can first be heard. \ Feet \ Feet decibels. (acc. to ANSI Z24.5-1951)

Average: Average:

5. BLOOD PRESSURE/ PULSE RATE Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.

Blood Systolic Diastolic Pressure

Driver qualified if <140/90.

Pulse Rate: Regular Irregular

LABORATORY AND OTHER TEST FINDINGS SP. GR. PROTEIN BLOOD SUGAR URINE SPECIMEN

Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem. Other Testing (Describe and record)

6. Numerical readings must be recorded.

Reading Category Expiration Date Recertification

140-159/90-99 Stage 1 1 year 1 year if <140/90. One-time certificate for 3 months if 141-159/91-99.

160-179/100-109 Stage 2 One-time certificate for 3 months. 1 year from date of exam if <140/90

>180/110 Stage 3 6 months from date of exam if <140/90 6 months if < 140/90

180

7 PHYSICAL EXAMINATION7. Name: Last, First, Middle,Height: (in.) Weight: (lbs.)

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. See Instructions to the Medical Examiner for guidance.

BODY SYSTEM 1. General Appearance

2. Eyes

3. Ears

4. Mouth and Throat

5. Heart

6. Lungs and chest, not including breast examination

CHECK FOR: Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse.

Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement,

aphakia, glaucoma, macular degeneration and refer to a specialist if appropriate.

Scarring of tympanic membrane, occlusion of external canal, perforated eardrums.

Irremediable deformities likely to interfere with breathing or swallowing.

Murmurs, extra sounds, enlarged heart, pacemaker, implantable defibrillator.

Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales,

physical exam may require further testing such as pulmonary tests and/ or xray of chest.

BODY SYSTEM

7. Abdomen and Viscera

8. Vascular System

9. Genito-urinary System

10. Extremities- Limb

be subject to SPE certificate if otherwise qualified.

11. Spine, other musculoskeletal

12. Neurological

CHECK FOR:

Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal wall muscle weakness.

Abnormal pulse and amplitude, cartoid or arterial bruits, varicose veins.

Hernias.

Loss or impairment of leg, foot, toe, arm, hand, finger, Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema,

in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly.

Previous surgery, deformities, limitation of motion, tenderness.

Impaired equilibrium, coordination or speech pattern; asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinki's reflexes, ataxia.

YES* NONOYES*

nystagmus, exophthalmos. Ask about retinopathy, cataracts,

impaired respiratory function, cyanosis. Abnormal findings on

impaired. Driver may

hypotonia. Insufficicent grasp and prehension

*COMMENTS:

Note certification status here. See Instructions to the Medical Examiner for guidance. Wearing corrective lense Wearing hearing aid

Meets standards in 49 CFR 391.41; qualifies for 2 year certificate Accompanied by a waiver/ exemption. Driver must present Does not meet standards exemption at time of certification.

. Skill Performanc e Evaluation (SPE) Certificate Driver qualified only for: 3 months 6 months 1 year Meets standards, but periodic monitoring required due to

Other Driving within an exempt intracity zone (See 49 CFR 391.62) Qualified by operation of 49 CFR 391.64

Medical Examiner's signature Temporarily disqualified due to (condition or medication): Medical Examiner's name

Address Return to medical examiner's office for follow up on Telephone Number

(Driver must carry certificate when operating a commercial vehicle.)If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h).

181

49 CFR 391.41 Physical Qualifications for Drivers

THE DRIVER'S ROLE Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main types of drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off-duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.) The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight pickup and delivery schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature. Transporting passengers or hazardous materials may add to the demands on the commercial driver. There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long period of time without any stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and, lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s). In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary, and the manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.

§391.45 PHYSICAL QUALIFICATIONS FOR DRIVERS(a) A person shall not drive a commercial motor vehicle unless he

is physically qualified to do so and, except as provided in §391.67, has on his person the original, or a photographic copy, of a medical examiner's certificate that he is physically qualified to drive a commercial motor vehicle.

(b) A person is physically qualified to drive a motor vehicle if thatperson:

(1) Has no loss of a foot, a leg, a hand, or an arm, or has beengranted a Skill Performance Evaluation (SPE) Certificate (formerly Limb Waiver Program) pursuant to §391.49.

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

(3) Has no established medical history or clinical diagnosis ofdiabetes mellitus currently requiring insulin for control;

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

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

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

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

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

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

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

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

(12) (i) Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. (ii) Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who: (A) Is familiar with the driver's medical history and assigned duties; and (B) Has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle; and

(13) Has no current clinical diagnosis ofalcoholism.

182

INSTRUCTIONS TO THE MEDICAL EXAMINER

General Information The purpose of this examination is to determine a driver's physical qualification to operate a commercial motor vehicle (CMV) in interstate commerce according to the requirements in 49 CFR 391.41-49. Therefore, the medical examiner must be knowledgeable of these requirements and guidelines developed by the FMCSA to assist the medical examiner in making the qualification determination. The medical examiner should be familiar with the driver's responsibilities and work environment and is referred to the section on the form, The Driver's Role.

In addition to reviewing the Health History section with the driver and conducting the physical examination, the medical examiner should discuss common prescriptions and over-the-counter medications relative to the side effects and hazards of these medications while driving. Educate the driver to read warning labels on all medications. History of certain conditions may be cause for rejection, particularly if required by regulation, or may indicate the need for additional laboratory tests or more stringent examination perhaps by a medical specialist. These decisions are usually made by the medical examiner in light of the driver's job responsibilities, work schedule and potential for the conditions to render the driver unsafe.

Medical conditions should be recorded even if they are not cause for denial, and they should be discussed with the driver to encourage appropriate remedial care. This advice is especially needed when a condition, if neglected, could develop into a serious illness that could affect driving.

If the medical examiner determines that the driver is fit to drive and is also able to perform non-driving responsibilities as may be required, the medical examiner signs the medical certificate which the driver must carry with his/her license. The certificate must be dated. Under current regulations, the certificate is valid for two years, unless the driver hasa medical condition that does not prohibit driving but does requiremore frequent monitoring. In such situations, the medical certificate should be issued for a shorter length of time. The physical examination should be done carefully and at least as complete as is indicated by the attached form. Contact the FMCSA at (202) 366-1790 for further information (a vision exemption, qualifying drivers under 49 CFR 391.64, etc.).

Interpretation of Medical StandardsSince the issuance of the regulations for physical qualifications of commercial drivers, the Federal Motor Carrier Safety Administration (FMCSA) has published recommendations called Advisory Criteria to help medical examiners in determining whether a driver meets the physical qualifications for commercial driving. These recommendations have been condensed to provide information to medical examiners that (1) is directly relevant to the physical examination and (2) is not already included in the medical examination form. The specific regulation is printed in italics and it's reference by section is highlighted.

Federal Motor Carrier Safety Regulations -Advisory Criteria-

Loss of Limb: §391.41(b)(1)A person is physically qualified to drive a commercial motor vehicle if that person: Has no loss of a foot, leg, hand or an arm, or has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

Limb Impairment:§391.41(b)(2)A person is physically qualified to drive a commercial motor vehicle if that person: Has no impairment of: (i) A hand or finger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iii) Any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iv) Has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

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

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

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

Diabetes §391.41(b)(3)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.

Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or disorientation in time and space. Individuals who require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semiconsciousness, diabetic coma or insulin shock).

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

Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualified under the present rule. CMV drivers who do not meet the Federal diabetes standard may call (202) 366-1790 for an application for a diabetes exemption. (See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Cardiovascular Condition §391.41(b)(4) A person is physically qualified to drive a commercialmotor vehicle if that person: Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse or congestive cardiac failure.

The term "has no current clinical diagnosis of" is specifically designed to encompass: "a clinical diagnosis of" (1) a current cardiovascular condition, or (2) a cardiovascular condition which has not fully stabilized regardless of the time limit The term "known to be 184

accompanied by" is designed to include a clinical diagnosis of a cardiovascular disease (1) which is accompanied by symptoms of syncope, dyspnea, collapse or congestive cardiac failure; and/or (2) which is likely to cause syncope, dyspnea, collapse or congestive cardiac failure.

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

Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus, not unqualifying. Implantable cardioverter defibrillators are disqualifying due to risk of syncope. Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver. The emphasis should be on the underlying medical condition(s) which require treatment and the general health of the driver. The FMCSA should be contacted at (202) 366-1790 for additional recommendations regarding the physical qualification of drivers on coumadin. (See Cardiovasular Advisory Panel Guidelines for the Medical examination of Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Respiratory Dysfunction§391.41(b)(5)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with ability to control and drive a commercial motor vehicle safely.

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

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

Hypertension §391.41(b)(6) A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of high blood pressure likely to interfere with ability to operate a commercial motor vehicle safely.

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

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

A blood pressure of 160-179 systolic and/or 100-109 diastolic is considered Stage 2 hypertension, and the driver is not necessarily unqualified during evaluation and institution of treatment. The driver is given a one time certification of three months to reduce his or her blood pressure to less than or equal to 140/90. A blood pressure in this range is an absolute indication for anti-hypertensive drug therapy. Provided treatment is well tolerated and the driver demonstrates a BP value of 140/90 or less, he or she may be certified for one year from date of the initial exam. The driver is certified annually thereafter.

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

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

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

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

Secondary hypertension is based on the above stages.

184

Epilepsy§391.41(b)(8)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a motor vehicle.

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

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

In those individual cases where a driver has a seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction, high temperature, acute infectious disease, dehydration or acute metabolic disturbance), certification should be deferred until the driver has fully recovered from that condition and has no existing residual complications, and not taking antiseizure medication.

Drivers with a history of epilepsy/seizures off antiseizure medication and seizure-free for 10 years may be qualified to drive a CMV in interstate commerce. Interstate drivers with a history of a single unprovoked seizure may be qualified to drive a CMV in interstate commerce if seizure-free and off antiseizure medication for a 5-year period or more. (See Conference on Neurological Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Mental Disorders §391.41(b)(9)A person is physically qualified to drive a commercial motor vehicle if that person: Has no mental, nervous, organic or functional disease or psychiatric disorder likely to interfere with ability to drive a motor vehicle safely.

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

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

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

Vision §391.41(b)(10)A person is physically qualified to drive a commercial motor vehicle if that person: Has distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.

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

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

If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner's Certificate: "Qualified only if wearing corrective lenses."

CMV drivers who do not meet the Federal vision standard may call (202) 366-1790 for an application for a vision exemption. (See Visual Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Hearing§391.41(b)(11)A person is physically qualified to drive a commercial motor vehicle if that person: First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ADA Standard) Z24.5-1951.

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

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

For the whispered voice test, the individual should be stationed at least 5 feet from the examiner with the ear being tested turned toward the examiner. The other ear is covered. Using the breath which remains after a normal expiration, the examiner whispers words or random numbers such as 66, 18,

186

23, etc. The examiner should not use only sibilants (s sounding materials). The opposite ear should be tested in the same manner. If the individual fails the whispered voice test, the audiometric test should be administered.

If an individual meets the criteria by the use of a hearing aid, the following statement must appear on the Medical Examiner's Certificate "Qualified only when wearing a hearing aid." (See Hearing Disorders and Commercial Motor Vehicle Drivers at: http://www/fmcsa.dot.gov/rulesregs/medrports.htm)

Drug Use§391.41(b)(12)A person is physically qualified to drive a commercial motor vehicle if that person: Does not use a controlled substance identified in 21 CFR 1308.II. Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who is familiar with the driver's medical history and assigned duties; and has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle. This exception does not apply to methadone. The intent of the medical certification process is to medically evaluate a driver to ensure that the driver has no medical condition which interferes with the safe performance of driving tasks on a public road. If a driver uses a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit-forming drug, it may be cause for the driver to be found medically unqualified. Motor carriers are encouraged to obtain a practitioner's written statement about the effects on transportation safety of the use of a particular drug.

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

The term "uses" is designed to encompass instances of prohibited drug use determined by a physician through established medical means. This may or may not involve body fluid testing. If body fluid testing takes place, positive test results should be confirmed by a second test of greater specificity. The term "habit-forming" is intended to include any drug or medication generally recognized as capable of becoming habitual, and which may impair the user's ability to operate a commercial motor vehicle safely.

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

Alcoholism §391.41(b)(13)A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of alcoholism.

The term "current clinical diagnosis of" is specifically designed to encompass a current alcoholic illness or those instances where the individual's physical condition has not fully stabilized, regardless of the time element. If an individual shows signs of having an alcohol-use problem, he or she should be referred to a specialist. After counseling

186

187

MEDICAL EXAMINER’S CERTIFICATE

I certify that I have examined _____________________________________________________________ in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when: wearing corrective lenses driving within an exempt intracity zone (49 CFR 391.62) wearing hearing aid accompanied by a Skill Performance Evaluation Certificate (SPE) accompanied by a______________________ waiver/exemption qualified by operation of 49 CFR 391.64 The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office.

SIGNATURE OF MEDICAL EXAMINER TELEPHONE DATE

MEDICAL EXAMINER’S NAME (PRINT) MD Chiropractor DO Advanced Practice Nurse Physician Assistant Other Practitioner

MEDICAL EXAMINER’S LICENSE OR CERTIFICATE NO./ISSUING STATE

NATIONAL REGISTRY NO.

SIGNATURE OF DRIVER INTRASTATE ONLY YES NO

CDL YES NO

DRIVER’S LICENSE NO. STATE

ADDRESS OF DRIVER

MEDICAL CERTIFICATION EXPIRATION DATE

189189

188

Medical Examination ReportFOR COMMERCIAL DRIVER FITNESS DETERMINATION

649-F (6045)

1. DRIVER'S INFORMATION Driver completes this section

Date of Exam M Recertification

M / D / Y

Driver's Name (Last, First, Middle) Social Security No. Birthdate Age Sex New Certification

F Follow-up

Address City, State, Zip Code Work Tel: ( ) Driver License No. License Class State of Issue A C B DHome Tel: ( )

Other

HEALTH HISTORY Driver completes this section, but medical examiner is encouraged to discuss with driver. 2.

Yes No Yes No Yes No Lung disease, emphysema, asthma, chronic bronchitis Fainting, dizziness

Any illness or injury in the last 5 years? Kidney disease, dialysis Sleep disorders, pauses in breathingHead/Brain injuries, disorders or illnesses Liver disease while asleep, daytime sleepiness, loudSeizures, epilepsy snoringDigestive problems

medication_______________________________ Diabetes or elevated blood sugar controlled by:

Stroke or paralysisEye disorders or impaired vision (except corrective lenses) diet Missing or impaired hand, arm, foot, leg,Ear disorders, loss of hearing or balance pills finger, toe Heart disease or heart attack; other cardiovascular condition insulin Spinal injury or disease

medication_______________________________ Nervous or psychiatric disorders, e.g., severe depression medication____________________ Chronic low back pain

Heart surgery (valve replacement/bypass, angioplasty, pacemaker) Regular, frequent alcohol useLoss of, or altered consciousnessHigh blood pressure medication___________________ Narcotic or habit forming drug useMuscular disease Shortness of breath

For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including over-the-counter medications) used regularly or recently.

I certify that the above information is complete and true. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner's Certificate.

Driver's Signature Date

Medical Examiner's Comments on Health History (The medical examiner must review and discuss with the driver any "yes" answers and potential hazards of medications, including over-the-counter medications, while driving. This discussion must be documented below. )

179

TESTING (Medical Examiner completes Section 3 through 7) Name: Last, First, Middle,

3. VISION Standard: At least 20/40 acuity (Snellen) in each eye with or without correction. At least 70 degrees peripheral in horizontal meridian measured in each eye. The use of corrective lenses should be noted on the Medical Examiner's Certificate.

INSTRUCTIONS: When other than the Snellen chart is used, give test results in Snellen-comparable values. In recording distance vision, use 20 feet as normal. Report visual acuity as a ratio with 20 as numerator and the smallest type read at 20 feet as denominator. If the applicant wears corrective lenses, these should be worn while visual acuity is being tested. If the driver habitually wears contact lenses, or intends to do so while driving, sufficient evidence of good tolerance and adaptation to their use must be obvious. Monocular drivers are not qualified.

Numerical readings must be provided. Applicant can recognize and distinguish among traffic control Yes

HORIZONTAL FIELD OF VISIONACUITYACUITY UNCORRECTEDUNCORRECTED CORRECTEDCORRECTED

Right EyeRight EyeRight EyeRight Eye 20/20/ 20/20/

Left EyeLeft Eye 20/20/ 20/20/ Left EyeLeft Eye

Both EyesBoth Eyes 20/20/ 20/20/

signals and devices showing standard red, green, and amber colors ? No

Applicant meets visual acuity requirement only when wearing: Corrective Lenses

Monocular Vision: Yes No

Complete next line only if vision testing is done by an opthalmologist or optometrist

Date of Examination Name of Ophthalmologist or Optometrist (print) Tel. No. License No./ State of Issue Signature

4. HEARING Standard: a) Must first perceive forced whispered voice > 5 ft., with or without hearing aid, or b) average hearing loss in better ear < 40 dB Check if hearing aid used for tests. Check if hearing aid required to meet standard.

INSTRUCTIONS: To convert audiometric test results from ISO to ANSI, -14 dB from ISO for 500Hz, -10dB for 1,000 Hz, -8.5 dB for 2000 Hz. To average, add the readings for 3 frequencies tested and divide by 3.

Numerical readings must be recorded. Right Ear Left Ear

a) Record distance from individual at which Right ear Left Ear b) If audiometer is used, record hearing loss in 500 Hz 1000 Hz 2000 Hz 500 Hz 1000 Hz 2000 Hz forced whispered voice can first be heard. \ Feet \ Feet decibels. (acc. to ANSI Z24.5-1951)

Average: Average:

5. BLOOD PRESSURE/ PULSE RATE Numerical readings must be recorded. Medical Examiner should take at least two readings to confirm BP.

Blood Systolic Diastolic Pressure

Driver qualified if <140/90.

Pulse Rate: Regular Irregular

LABORATORY AND OTHER TEST FINDINGS SP. GR. PROTEIN BLOOD SUGAR URINE SPECIMEN

Urinalysis is required. Protein, blood or sugar in the urine may be an indication for further testing to rule out any underlying medical problem. Other Testing (Describe and record)

6. Numerical readings must be recorded.

Reading Category Expiration Date Recertification

140-159/90-99 Stage 1 1 year 1 year if <140/90. One-time certificate for 3 months if 141-159/91-99.

160-179/100-109 Stage 2 One-time certificate for 3 months. 1 year from date of exam if <140/90

>180/110 Stage 3 6 months from date of exam if <140/90 6 months if < 140/90

180

7 PHYSICAL EXAMINATION7. Name: Last, First, Middle,Height: (in.) Weight: (lbs.)

The presence of a certain condition may not necessarily disqualify a driver, particularly if the condition is controlled adequately, is not likely to worsen or is readily amenable to treatment. Even if a condition does not disqualify a driver, the medical examiner may consider deferring the driver temporarily. Also, the driver should be advised to take the necessary steps to correct the condition as soon as possible particularly if the condition, if neglected, could result in more serious illness that might affect driving.

Check YES if there are any abnormalities. Check NO if the body system is normal. Discuss any YES answers in detail in the space below, and indicate whether it would affect the driver's ability to operate a commercial motor vehicle safely. Enter applicable item number before each comment. If organic disease is present, note that it has been compensated for. See Instructions to the Medical Examiner for guidance.

BODY SYSTEM 1. General Appearance

2. Eyes

3. Ears

4. Mouth and Throat

5. Heart

6. Lungs and chest, not including breast examination

CHECK FOR: Marked overweight, tremor, signs of alcoholism, problem drinking, or drug abuse.

Pupillary equality, reaction to light, accommodation, ocular motility, ocular muscle imbalance, extraocular movement,

aphakia, glaucoma, macular degeneration and refer to a specialist if appropriate.

Scarring of tympanic membrane, occlusion of external canal, perforated eardrums.

Irremediable deformities likely to interfere with breathing or swallowing.

Murmurs, extra sounds, enlarged heart, pacemaker, implantable defibrillator.

Abnormal chest wall expansion, abnormal respiratory rate, abnormal breath sounds including wheezes or alveolar rales,

physical exam may require further testing such as pulmonary tests and/ or xray of chest.

BODY SYSTEM

7. Abdomen and Viscera

8. Vascular System

9. Genito-urinary System

10. Extremities- Limb

be subject to SPE certificate if otherwise qualified.

11. Spine, other musculoskeletal

12. Neurological

CHECK FOR:

Enlarged liver, enlarged spleen, masses, bruits, hernia, significant abdominal wall muscle weakness.

Abnormal pulse and amplitude, cartoid or arterial bruits, varicose veins.

Hernias.

Loss or impairment of leg, foot, toe, arm, hand, finger, Perceptible limp, deformities, atrophy, weakness, paralysis, clubbing, edema,

in upper limb to maintain steering wheel grip. Insufficient mobility and strength in lower limb to operate pedals properly.

Previous surgery, deformities, limitation of motion, tenderness.

Impaired equilibrium, coordination or speech pattern; asymmetric deep tendon reflexes, sensory or positional abnormalities, abnormal patellar and Babinki's reflexes, ataxia.

YES* NONOYES*

nystagmus, exophthalmos. Ask about retinopathy, cataracts,

impaired respiratory function, cyanosis. Abnormal findings on

impaired. Driver may

hypotonia. Insufficicent grasp and prehension

*COMMENTS:

Note certification status here. See Instructions to the Medical Examiner for guidance. Wearing corrective lense Wearing hearing aid

Meets standards in 49 CFR 391.41; qualifies for 2 year certificate Accompanied by a waiver/ exemption. Driver must present Does not meet standards exemption at time of certification.

. Skill Performanc e Evaluation (SPE) Certificate Driver qualified only for: 3 months 6 months 1 year Meets standards, but periodic monitoring required due to

Other Driving within an exempt intracity zone (See 49 CFR 391.62) Qualified by operation of 49 CFR 391.64

Medical Examiner's signature Temporarily disqualified due to (condition or medication): Medical Examiner's name

Address Return to medical examiner's office for follow up on Telephone Number

(Driver must carry certificate when operating a commercial vehicle.)If meets standards, complete a Medical Examiner's Certificate as stated in 49 CFR 391.43(h).

181

49 CFR 391.41 Physical Qualifications for Drivers

THE DRIVER'S ROLE Responsibilities, work schedules, physical and emotional demands, and lifestyles among commercial drivers vary by the type of driving that they do. Some of the main types of drivers include the following: turn around or short relay (drivers return to their home base each evening); long relay (drivers drive 9-11 hours and then have at least a 10-hour off-duty period), straight through haul (cross country drivers); and team drivers (drivers share the driving by alternating their 5-hour driving periods and 5-hour rest periods.) The following factors may be involved in a driver's performance of duties: abrupt schedule changes and rotating work schedules, which may result in irregular sleep patterns and a driver beginning a trip in a fatigued condition; long hours; extended time away from family and friends, which may result in lack of social support; tight pickup and delivery schedules, with irregularity in work, rest, and eating patterns, adverse road, weather and traffic conditions, which may cause delays and lead to hurriedly loading or unloading cargo in order to compensate for the lost time; and environmental conditions such as excessive vibration, noise, and extremes in temperature. Transporting passengers or hazardous materials may add to the demands on the commercial driver. There may be duties in addition to the driving task for which a driver is responsible and needs to be fit. Some of these responsibilities are: coupling and uncoupling trailer(s) from the tractor, loading and unloading trailer(s) (sometimes a driver may lift a heavy load or unload as much as 50,000 lbs. of freight after sitting for a long period of time without any stretching period); inspecting the operating condition of tractor and/or trailer(s) before, during and after delivery of cargo; lifting, installing, and removing heavy tire chains; and, lifting heavy tarpaulins to cover open top trailers. The above tasks demand agility, the ability to bend and stoop, the ability to maintain a crouching position to inspect the underside of the vehicle, frequent entering and exiting of the cab, and the ability to climb ladders on the tractor and/or trailer(s). In addition, a driver must have the perceptual skills to monitor a sometimes complex driving situation, the judgment skills to make quick decisions, when necessary, and the manipulative skills to control an oversize steering wheel, shift gears using a manual transmission, and maneuver a vehicle in crowded areas.

§391.45 PHYSICAL QUALIFICATIONS FOR DRIVERS(a) A person shall not drive a commercial motor vehicle unless he

is physically qualified to do so and, except as provided in §391.67, has on his person the original, or a photographic copy, of a medical examiner's certificate that he is physically qualified to drive a commercial motor vehicle.

(b) A person is physically qualified to drive a motor vehicle if thatperson:

(1) Has no loss of a foot, a leg, a hand, or an arm, or has beengranted a Skill Performance Evaluation (SPE) Certificate (formerly Limb Waiver Program) pursuant to §391.49.

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

(3) Has no established medical history or clinical diagnosis ofdiabetes mellitus currently requiring insulin for control;

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

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

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

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

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

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

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

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

(12) (i) Does not use a controlled substance identified in 21 CFR 1308.11 Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. (ii) Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who: (A) Is familiar with the driver's medical history and assigned duties; and (B) Has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle; and

(13) Has no current clinical diagnosis ofalcoholism.

182

INSTRUCTIONS TO THE MEDICAL EXAMINER

General Information The purpose of this examination is to determine a driver's physical qualification to operate a commercial motor vehicle (CMV) in interstate commerce according to the requirements in 49 CFR 391.41-49. Therefore, the medical examiner must be knowledgeable of these requirements and guidelines developed by the FMCSA to assist the medical examiner in making the qualification determination. The medical examiner should be familiar with the driver's responsibilities and work environment and is referred to the section on the form, The Driver's Role.

In addition to reviewing the Health History section with the driver and conducting the physical examination, the medical examiner should discuss common prescriptions and over-the-counter medications relative to the side effects and hazards of these medications while driving. Educate the driver to read warning labels on all medications. History of certain conditions may be cause for rejection, particularly if required by regulation, or may indicate the need for additional laboratory tests or more stringent examination perhaps by a medical specialist. These decisions are usually made by the medical examiner in light of the driver's job responsibilities, work schedule and potential for the conditions to render the driver unsafe.

Medical conditions should be recorded even if they are not cause for denial, and they should be discussed with the driver to encourage appropriate remedial care. This advice is especially needed when a condition, if neglected, could develop into a serious illness that could affect driving.

If the medical examiner determines that the driver is fit to drive and is also able to perform non-driving responsibilities as may be required, the medical examiner signs the medical certificate which the driver must carry with his/her license. The certificate must be dated. Under current regulations, the certificate is valid for two years, unless the driver hasa medical condition that does not prohibit driving but does requiremore frequent monitoring. In such situations, the medical certificate should be issued for a shorter length of time. The physical examination should be done carefully and at least as complete as is indicated by the attached form. Contact the FMCSA at (202) 366-1790 for further information (a vision exemption, qualifying drivers under 49 CFR 391.64, etc.).

Interpretation of Medical StandardsSince the issuance of the regulations for physical qualifications of commercial drivers, the Federal Motor Carrier Safety Administration (FMCSA) has published recommendations called Advisory Criteria to help medical examiners in determining whether a driver meets the physical qualifications for commercial driving. These recommendations have been condensed to provide information to medical examiners that (1) is directly relevant to the physical examination and (2) is not already included in the medical examination form. The specific regulation is printed in italics and it's reference by section is highlighted.

Federal Motor Carrier Safety Regulations -Advisory Criteria-

Loss of Limb: §391.41(b)(1)A person is physically qualified to drive a commercial motor vehicle if that person: Has no loss of a foot, leg, hand or an arm, or has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

Limb Impairment:§391.41(b)(2)A person is physically qualified to drive a commercial motor vehicle if that person: Has no impairment of: (i) A hand or finger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iii) Any other significant limb defect or limitation which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or (iv) Has been granted a Skill Performance Evaluation (SPE) Certificate pursuant to Section 391.49.

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

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

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

Diabetes §391.41(b)(3)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of diabetes mellitus currently requiring insulin for control.

Diabetes mellitus is a disease which, on occasion, can result in a loss of consciousness or disorientation in time and space. Individuals who require insulin for control have conditions which can get out of control by the use of too much or too little insulin, or food intake not consistent with the insulin dosage. Incapacitation may occur from symptoms of hyperglycemic or hypoglycemic reactions (drowsiness, semiconsciousness, diabetic coma or insulin shock).

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

Hypoglycemic drugs, taken orally, are sometimes prescribed for diabetic individuals to help stimulate natural body production of insulin. If the condition can be controlled by the use of oral medication and diet, then an individual may be qualified under the present rule. CMV drivers who do not meet the Federal diabetes standard may call (202) 366-1790 for an application for a diabetes exemption. (See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Cardiovascular Condition §391.41(b)(4) A person is physically qualified to drive a commercialmotor vehicle if that person: Has no current clinical diagnosis of myocardial infarction, angina pectoris, coronary insufficiency, thrombosis or any other cardiovascular disease of a variety known to be accompanied by syncope, dyspnea, collapse or congestive cardiac failure.

The term "has no current clinical diagnosis of" is specifically designed to encompass: "a clinical diagnosis of" (1) a current cardiovascular condition, or (2) a cardiovascular condition which has not fully stabilized regardless of the time limit The term "known to be 184

accompanied by" is designed to include a clinical diagnosis of a cardiovascular disease (1) which is accompanied by symptoms of syncope, dyspnea, collapse or congestive cardiac failure; and/or (2) which is likely to cause syncope, dyspnea, collapse or congestive cardiac failure.

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

Coronary artery bypass surgery and pacemaker implantation are remedial procedures and thus, not unqualifying. Implantable cardioverter defibrillators are disqualifying due to risk of syncope. Coumadin is a medical treatment which can improve the health and safety of the driver and should not, by its use, medically disqualify the commercial driver. The emphasis should be on the underlying medical condition(s) which require treatment and the general health of the driver. The FMCSA should be contacted at (202) 366-1790 for additional recommendations regarding the physical qualification of drivers on coumadin. (See Cardiovasular Advisory Panel Guidelines for the Medical examination of Commercial Motor Vehicle Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Respiratory Dysfunction§391.41(b)(5)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of a respiratory dysfunction likely to interfere with ability to control and drive a commercial motor vehicle safely.

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

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

Hypertension §391.41(b)(6) A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of high blood pressure likely to interfere with ability to operate a commercial motor vehicle safely.

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

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

A blood pressure of 160-179 systolic and/or 100-109 diastolic is considered Stage 2 hypertension, and the driver is not necessarily unqualified during evaluation and institution of treatment. The driver is given a one time certification of three months to reduce his or her blood pressure to less than or equal to 140/90. A blood pressure in this range is an absolute indication for anti-hypertensive drug therapy. Provided treatment is well tolerated and the driver demonstrates a BP value of 140/90 or less, he or she may be certified for one year from date of the initial exam. The driver is certified annually thereafter.

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

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

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

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

Secondary hypertension is based on the above stages.

184

Epilepsy§391.41(b)(8)A person is physically qualified to drive a commercial motor vehicle if that person: Has no established medical history or clinical diagnosis of epilepsy or any other condition which is likely to cause loss of consciousness or any loss of ability to control a motor vehicle.

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

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

In those individual cases where a driver has a seizure or an episode of loss of consciousness that resulted from a known medical condition (e.g., drug reaction, high temperature, acute infectious disease, dehydration or acute metabolic disturbance), certification should be deferred until the driver has fully recovered from that condition and has no existing residual complications, and not taking antiseizure medication.

Drivers with a history of epilepsy/seizures off antiseizure medication and seizure-free for 10 years may be qualified to drive a CMV in interstate commerce. Interstate drivers with a history of a single unprovoked seizure may be qualified to drive a CMV in interstate commerce if seizure-free and off antiseizure medication for a 5-year period or more. (See Conference on Neurological Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Mental Disorders §391.41(b)(9)A person is physically qualified to drive a commercial motor vehicle if that person: Has no mental, nervous, organic or functional disease or psychiatric disorder likely to interfere with ability to drive a motor vehicle safely.

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

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

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

Vision §391.41(b)(10)A person is physically qualified to drive a commercial motor vehicle if that person: Has distant visual acuity of at least 20/40 (Snellen) in each eye with or without corrective lenses or visual acuity separately corrected to 20/40 (Snellen) or better with corrective lenses, distant binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, field of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green, and amber.

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

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

If an individual meets the criteria by the use of glasses or contact lenses, the following statement shall appear on the Medical Examiner's Certificate: "Qualified only if wearing corrective lenses."

CMV drivers who do not meet the Federal vision standard may call (202) 366-1790 for an application for a vision exemption. (See Visual Disorders and Commercial Drivers at: http://www.fmcsa.dot.gov/rulesregs/medreports.htm)

Hearing§391.41(b)(11)A person is physically qualified to drive a commercial motor vehicle if that person: First perceives a forced whispered voice in the better ear at not less than 5 feet with or without the use of a hearing aid, or, if tested by use of an audiometric device, does not have an average hearing loss in the better ear greater than 40 decibels at 500 Hz, 1,000 Hz, and 2,000 Hz with or without a hearing aid when the audiometric device is calibrated to American National Standard (formerly ADA Standard) Z24.5-1951.

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

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

For the whispered voice test, the individual should be stationed at least 5 feet from the examiner with the ear being tested turned toward the examiner. The other ear is covered. Using the breath which remains after a normal expiration, the examiner whispers words or random numbers such as 66, 18,

186

23, etc. The examiner should not use only sibilants (s sounding materials). The opposite ear should be tested in the same manner. If the individual fails the whispered voice test, the audiometric test should be administered.

If an individual meets the criteria by the use of a hearing aid, the following statement must appear on the Medical Examiner's Certificate "Qualified only when wearing a hearing aid." (See Hearing Disorders and Commercial Motor Vehicle Drivers at: http://www/fmcsa.dot.gov/rulesregs/medrports.htm)

Drug Use§391.41(b)(12)A person is physically qualified to drive a commercial motor vehicle if that person: Does not use a controlled substance identified in 21 CFR 1308.II. Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. Exception: A driver may use such a substance or drug, if the substance or drug is prescribed by a licensed medical practitioner who is familiar with the driver's medical history and assigned duties; and has advised the driver that the prescribed substance or drug will not adversely affect the driver's ability to safely operate a commercial motor vehicle. This exception does not apply to methadone. The intent of the medical certification process is to medically evaluate a driver to ensure that the driver has no medical condition which interferes with the safe performance of driving tasks on a public road. If a driver uses a Schedule I drug or other substance, an amphetamine, a narcotic, or any other habit-forming drug, it may be cause for the driver to be found medically unqualified. Motor carriers are encouraged to obtain a practitioner's written statement about the effects on transportation safety of the use of a particular drug.

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

The term "uses" is designed to encompass instances of prohibited drug use determined by a physician through established medical means. This may or may not involve body fluid testing. If body fluid testing takes place, positive test results should be confirmed by a second test of greater specificity. The term "habit-forming" is intended to include any drug or medication generally recognized as capable of becoming habitual, and which may impair the user's ability to operate a commercial motor vehicle safely.

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

Alcoholism §391.41(b)(13)A person is physically qualified to drive a commercial motor vehicle if that person: Has no current clinical diagnosis of alcoholism.

The term "current clinical diagnosis of" is specifically designed to encompass a current alcoholic illness or those instances where the individual's physical condition has not fully stabilized, regardless of the time element. If an individual shows signs of having an alcohol-use problem, he or she should be referred to a specialist. After counseling

186

187

MEDICAL EXAMINER’S CERTIFICATE

I certify that I have examined _____________________________________________________________ in accordance with the Federal Motor Carrier Safety Regulations (49 CFR 391.41-391.49) and with knowledge of the driving duties, I find this person is qualified, and, if applicable, only when: wearing corrective lenses driving within an exempt intracity zone (49 CFR 391.62) wearing hearing aid accompanied by a Skill Performance Evaluation Certificate (SPE) accompanied by a______________________ waiver/exemption qualified by operation of 49 CFR 391.64 The information I have provided regarding this physical examination is true and complete. A complete examination form with any attachment embodies my findings completely and correctly, and is on file in my office.

SIGNATURE OF MEDICAL EXAMINER TELEPHONE DATE

MEDICAL EXAMINER’S NAME (PRINT) MD Chiropractor DO Advanced Practice Nurse Physician Assistant Other Practitioner

MEDICAL EXAMINER’S LICENSE OR CERTIFICATE NO./ISSUING STATE

NATIONAL REGISTRY NO.

SIGNATURE OF DRIVER INTRASTATE ONLY YES NO

CDL YES NO

DRIVER’S LICENSE NO. STATE

ADDRESS OF DRIVER

MEDICAL CERTIFICATION EXPIRATION DATE

189189

188

Documents

Commercial Driver Medical Examiner Training: Improving … Driver ME... · person training for health care professionals who perform physical examinations for Commercial Motor Vehicle