Dot Medical Template

Dot Medical Template

The DOT Medical Form is a Medical Examination Report used to assess the fitness of commercial drivers to operate a motor vehicle safely. This form collects essential information about a driver's health history, vision, hearing, and overall physical condition. Completing this form accurately is crucial for ensuring that drivers meet the necessary health standards required for their profession. To fill out the form, please click the button below.

Table of Contents

The DOT Medical form is an essential document for commercial drivers, serving as a comprehensive medical examination report that assesses their fitness to operate commercial motor vehicles. This form is divided into several key sections, starting with the driver's personal information, including their name, social security number, and medical history. Drivers must disclose any past illnesses or injuries, as well as current medications, which allows the medical examiner to evaluate potential risks associated with their health. Vision and hearing tests are crucial components, ensuring that drivers meet the required standards for safe operation. Blood pressure and pulse rate are also recorded, along with laboratory findings from urinalysis, which can indicate underlying health issues. The physical examination section covers various body systems, allowing the examiner to check for any abnormalities that could impair driving ability. This thorough assessment not only ensures compliance with federal regulations but also promotes safety on the roads by identifying drivers who may need further medical attention or monitoring.

Dot Medical Sample

Medical Examination Report
FOR 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
A
ddress City, State, Zip Code Work Tel: ( )
Driver License No.
License Class State of Issue
A C
B D
Home 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 breathing
Head/Brain injuries, disorders or illnesses
Liver disease
while asleep, daytime sleepiness, loud
Seizures, epilepsy
snoring
Digestive problems
medication_______________________________
Diabetes or elevated blood sugar controlled by:
Stroke or paralysis
Eye disorders or impaired vision (except corrective lenses)
diet
Missing or impaired hand, arm, foot, leg,
Ear disorders, loss of hearing or balance
pills
finger, toe
Heart disease or heart attack; other cardiovascular condition
insulin
Spinal injury or disease
medication_______________________________
Nervous or psychiatric disorders, e.g., severe depression
medication____________________
Chronic low back pain
Heart surgery (valve replacement/bypass, angioplasty,
pacemaker)
Regular, frequent alcohol use
Loss of, or altered consciousness
High blood pressure medication___________________
Narcotic or habit forming drug use
Muscular disease
Shortness of breath
For any YES answer, indicate onset date, diagnosis, treating physician's name and address, and any current limitation. List all medications (including
over-the-counter medications) used regularly or recently.
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. )
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 VISION
A
CUITY
A
CUITY UNCORRECTEDUNCORRECTED CORRECTEDCORRECTED
Right Eye
Right Eye
Right Eye
Right Eye
20/
20/
20/
20/
Left Eye
Left Eye
20/
20/
20/
20/
Left Eye
Left Eye
Both Eyes
Both Eyes
20/
20/
20/
20/
signals and devices showing standard red, green, and amber colors ?
No
A
pplicant 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
fre
q
uencies tested and divide b
y 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
7 PHYSICAL EXAMINATION
7.
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.
A
bnormal 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.
A
bnormal 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
*
NO
NO
YES*
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).
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 mani
p
ulative skills to control an oversize steerin
g
wheel
,
shift
g
ears usin
g
a manual transmission
,
and maneuver a vehicle in crowded areas.
§391.45 PHYSICAL QUALIFICATIONS FOR DRIVERS
(a) A person shall not drive a commercial motor vehicle unless he
is physically qualified to do so and, except as provided in §391.67,
has on his person the original, or a photographic copy, of a medical
examiner's certificate that he is physically qualified to drive a
commercial motor vehicle.
(b) A person is physically qualified to drive a motor vehicle if that
person:
(1) Has no loss of a foot, a leg, a hand, or an arm, or has been
granted a Skill Performance Evaluation (SPE) Certificate (formerly
Limb Waiver Program) pursuant to §391.49.
(2) Has no impairment of: (i) A hand or finger which interferes
with prehension or power grasping; or (ii) An arm, foot, or leg whic
interferes with the ability to perform normal tasks associated with
operating a commercial motor vehicle; or any other significant limb
defect or limitation which interferes with the ability to perform normal
tasks associated with operating a commercial motor vehicle; or has
been granted a SPE Certificate pursuant to §391.49.
(3) Has no established medical history or clinical diagnosis of
diabetes mellitus currently requiring insulin for control;
(4) Has no current clinical diagnosis of myocardial infarction,
angina pectoris, coronary insufficiency, thrombosis, or any other
cardiovascular disease of a variety known to be accompanied by
syncope, dyspnea, collapse, or congestive cardiac failure.
(5) Has no established medical history or clinical diagnosis of a
respiratory dysfunction likely to interfere with his ability to control and
drive a commercial motor vehicle safely.
(6) Has no current clinical diagnosis of high blood pressure
likely to interfere with his ability to operate a commercial motor
vehicle safel
y
.
(7) Has no established medical history or clinical
diagnosis of rheumatic, arthritic, orthopedic, muscular,
neuromuscular, or vascular disease which interferes with his
ability to control and operate a commercial motor vehicle safely.
(8) Has no established medical history or clinical
diagnosis of epilepsy or any other condition which is likely to
cause loss of consciousness or any loss of ability to control a
commercial motor vehicle;
(9) Has no mental, nervous, organic, or functional
disease or psychiatric disorder likely to interfere with his ability
to drive a commercial motor vehicle safely;
(10) Has distant visual acuity of at least 20/40 (Snellen)
in each eye without corrective lenses or visual acuity separately
corrected to 20/40 (Snellen) or better with corrective lenses,
distant binocular acuity of at least 20/40 (Snellen) in both eyes
with or without corrective lenses, field of vision of at least 7
0
degrees in the horizontal meridian in each eye, and the ability
to recognize the colors of traffic signals and devices showing
standard red, green and amber;
(11) First perceives a forced whispered voice in the
better ear not less than 5 feet with or without the use of a
hearing aid, or, if tested by use of an audiometric device, does
not have an average hearing loss in the better ear greater than
40 decibels at 500 Hz, 1,000 Hz and 2,000 Hz with or without a
hearing device when the audiometric device is calibrated to the
A
merican National Standard (formerly ASA Standard)
Z24.5-1951;
(12) (i) Does not use a controlled
substance identified in 21 CFR 1308.11 Schedule
I, an amphetamine, a narcotic, or any other
habit-forming drug. (ii) Exception: A driver may
use such a substance or drug, if the substance or
drug is prescribed by a licensed medical
practitioner who: (A) Is familiar with the driver's
medical history and assigned duties; and (B) Has
advised the driver that the prescribed substance
or drug will not adversely affect the driver's ability
to safely operate a commercial motor vehicle; and
(13) Has no current clinical diagnosis of
alcoholism.
INSTRUCTIONS TO THE MEDICAL EXAMINER
General Information
The purpose of this examination is to determine a driver's physical
qualification to operate a commercial motor vehicle (CMV) in interstate
commerce according to the requirements in 49 CFR 391.41-49. Therefore,
the medical examiner must be knowledgeable of these requirements and
guidelines developed by the FMCSA to assist the medical examiner in
making the qualification determination. The medical examiner should be
familiar with the driver's responsibilities and work environment and is
referred to the section on the form,
The Driver's Role
.
In addition to reviewing the
Health History
section with the driver and
conducting the physical examination, the medical examiner should discuss
common prescriptions and over-the-counter medications relative to the side
effects and hazards of these medications while driving. Educate the driver
to read warning labels on all medications. History of certain conditions may
be cause for rejection, particularly if required by regulation, or may indicate
the need for additional laboratory tests or more stringent examination
perhaps by a medical specialist. These decisions are usually made by the
medical examiner in light of the driver's job responsibilities, work schedule
and potential for the conditions to render the driver unsafe.
Medical conditions should be recorded even if they are not cause for
denial, and they should be discussed with the driver to encourage
appropriate remedial care. This advice is especially needed when a
condition, if neglected, could develop into a serious illness that could affect
driving.
If the medical examiner determines that the driver is fit to drive and is
also able to perform non-driving responsibilities as may be required, the
medical examiner signs the medical certificate which the driver must carry
with his/her license. The certificate must be dated.
Under current
regulations, the certificate is valid for two years, unless the driver has
a medical condition that does not prohibit driving but does require
more frequent monitoring
. In such situations, the medical certificate
should be issued for a shorter length of time. The physical examination
should be done carefully and at least as complete as is indicated by the
attached form. Contact the FMCSA at (202) 366-1790 for further
information (a vision exemption, qualifying drivers under 49 CFR 391.64,
etc.).
Interpretation of Medical Standards
Since the issuance of the regulations for physical qualifications of
commercial drivers, the Federal Motor Carrier Safety Administration
(FMCSA) has published recommendations called Advisory Criteria to help
medical examiners in determining whether a driver meets the physical
qualifications for commercial driving. These recommendations have been
condensed to provide information to medical examiners that (1) is directly
relevant to the physical examination and (2) is not already included in the
medical examination form. The specific regulation is printed in italics and
it's reference by section is highlighted.
Federal Motor Carrier Safety Regulations
-Advisory 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 commercial
motor vehicle if that p
erson:
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
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.
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,
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
▼ Dot Medical PDF Form

Document Attributes

Fact Name Description
Purpose The DOT Medical form is used to assess the physical fitness of commercial drivers to ensure they can operate vehicles safely.
Driver Information Drivers must provide personal details, including their name, social security number, and medical history.
Health History Drivers must disclose any medical conditions or injuries from the last five years that could affect their driving ability.
Vision Standards Drivers must have at least 20/40 vision in each eye, with or without corrective lenses, and a horizontal field of vision of at least 70 degrees.
Hearing Standards Drivers must perceive a forced whispered voice from at least five feet away, with or without a hearing aid.
Blood Pressure Requirements Blood pressure must be below 140/90 for a driver to be considered qualified; higher readings may lead to more frequent monitoring.
Medication Disclosure Drivers must list all medications they are taking, as some may affect their ability to drive safely.
Certification Validity The medical certificate is generally valid for two years unless specific medical conditions require more frequent evaluations.
Governing Laws The form and its requirements are governed by federal regulations, specifically 49 CFR 391.41 - 49 CFR 391.49.

Dot Medical: Usage Instruction

Filling out the DOT Medical form is a crucial step in ensuring that commercial drivers meet the necessary health standards to operate vehicles safely. The process involves providing personal information, a detailed health history, and undergoing various medical evaluations. Completing this form accurately is essential, as it can impact a driver's certification status and ability to work.

  1. Begin by entering your personal details in the "DRIVER'S INFORMATION" section. Include your full name (last, first, middle), Social Security number, birthdate, age, sex, and whether this is a new certification, recertification, or follow-up.
  2. Provide your address, city, state, and zip code, along with your work and home telephone numbers.
  3. Fill in your driver’s license number, class, and state of issue.
  4. Proceed to the "HEALTH HISTORY" section. Answer the questions regarding any illnesses or injuries in the last five years, and provide details for any "yes" answers, including onset dates, diagnoses, treating physician's name, and current limitations.
  5. List all medications you currently use, including over-the-counter drugs.
  6. Sign and date the certification statement to confirm the accuracy of your information.
  7. Next, the medical examiner will complete the "TESTING" sections (3 through 7). This includes vision, hearing, blood pressure, and other laboratory tests. Ensure you are prepared for these evaluations.
  8. For the vision test, be aware that you need to achieve at least 20/40 acuity in each eye, and if you wear corrective lenses, bring them for the test.
  9. For the hearing test, be ready to demonstrate your ability to perceive a forced whispered voice or have an audiometric test done.
  10. The medical examiner will also check your blood pressure and pulse rate, so be prepared for these measurements.
  11. Finally, the medical examiner will document any additional findings from your physical examination. This may include notes on your general appearance, eyes, heart, lungs, and other body systems.

Frequently Asked Questions

  1. What is the purpose of the DOT Medical Form?

    The DOT Medical Form, formally known as the Medical Examination Report for Commercial Driver Fitness Determination, is designed to assess whether a commercial driver is physically qualified to operate a commercial motor vehicle. This form is essential for ensuring that drivers meet specific health standards set by the Federal Motor Carrier Safety Administration (FMCSA). It includes sections for the driver's personal information, health history, and results from various medical tests conducted by a certified medical examiner.

  2. Who is responsible for completing the DOT Medical Form?

    Both the driver and the medical examiner have roles in completing the DOT Medical Form. The driver is responsible for filling out their personal information and health history. This includes answering questions about any past illnesses, injuries, or medications. The medical examiner, on the other hand, conducts a physical examination and evaluates the driver's health based on the information provided. The medical examiner must also document any discussions regarding the driver's health and any potential risks associated with their medical conditions or medications.

  3. What are the health standards that drivers must meet?

    Drivers must meet several health standards to be considered physically qualified. Key requirements include:

    • Vision acuity of at least 20/40 in each eye, with or without corrective lenses.
    • A hearing ability to perceive a forced whispered voice from at least 5 feet away.
    • Blood pressure readings below 140/90.
    • No significant medical history that could impair the ability to safely operate a commercial vehicle, such as certain cardiovascular, respiratory, or neurological conditions.

    Meeting these standards helps ensure that drivers can safely perform their duties without risking their health or the safety of others on the road.

  4. How often do drivers need to complete the DOT Medical Form?

    Typically, drivers are required to complete the DOT Medical Form every two years. However, if a driver has specific medical conditions that necessitate more frequent monitoring, the medical examiner may issue a certificate for a shorter duration, such as 3 or 6 months. It’s important for drivers to stay aware of their health status and to follow up with their medical examiner as needed to ensure compliance with the regulations.

Common mistakes

Filling out the DOT Medical form can be a straightforward process, but there are common mistakes that individuals often make. One frequent error is failing to provide complete personal information. For instance, omitting the driver's name or Social Security number can lead to delays in processing the form. It is essential to ensure that all fields are filled out accurately to avoid complications.

Another mistake is neglecting to disclose relevant health history. The form includes a section where drivers must indicate any illnesses or injuries they have experienced in the last five years. Some individuals may forget to mention past conditions, thinking they are not significant. However, all health issues should be reported, as they can impact the driver's fitness for duty.

Drivers sometimes overlook the importance of listing all medications they are currently taking. This includes prescription and over-the-counter drugs. Not providing this information can result in misunderstandings about the driver's health status and may invalidate the medical examination.

Inaccurate vision test results are another common error. Drivers must ensure they meet the visual acuity standards and report their results correctly. If corrective lenses are used, this must be noted on the form. Misreporting vision can lead to disqualification from driving commercial vehicles.

Some individuals fail to have their hearing tested correctly. The form specifies that drivers must first perceive a forced whispered voice from a certain distance or meet specific audiometric standards. Not adhering to these requirements can lead to complications in the certification process.

Another mistake is not providing sufficient detail for any "yes" answers in the health history section. If a driver indicates they have a health issue, they must include details such as the onset date, diagnosis, and current limitations. Failing to do so may raise concerns during the review process.

Additionally, drivers sometimes skip signing the form or forget to date it. The driver's signature is a crucial part of the certification process, and an unsigned form will not be valid. It is important to double-check that all necessary signatures are included.

Many drivers do not take the time to review the medical examiner's comments section. This area is vital for documenting any discussions about health concerns or medications. Ignoring this can lead to misunderstandings about the driver's fitness for duty.

Another common issue is not keeping a copy of the completed form. Having a copy can be helpful for personal records and for any future reference. It is advisable to maintain documentation of the medical examination.

Lastly, some drivers may not follow up with the medical examiner if they receive a temporary disqualification. Understanding the reasons for disqualification and the steps needed to rectify the situation is essential for ensuring compliance and maintaining the ability to drive commercially.

Documents used along the form

The DOT Medical form is a critical document for commercial drivers, but it is often accompanied by other important forms and documents that help ensure a driver's fitness to operate a commercial motor vehicle. Below are four common forms that may be used alongside the DOT Medical form.

  • Medical Examiner's Certificate: This certificate is issued by the medical examiner after evaluating the driver's health and fitness. It confirms that the driver meets the physical qualifications required to operate a commercial vehicle. The driver must carry this certificate while driving.
  • Vision Test Results: This document records the results of the driver's vision examination, which must meet specific standards. It includes details about visual acuity and peripheral vision, ensuring the driver can safely recognize traffic signals and navigate effectively.
  • Hearing Test Results: This form captures the results of the hearing examination. It verifies that the driver can perceive a forced whispered voice or has acceptable audiometric test results, which is essential for safe driving in various environments.
  • Skill Performance Evaluation (SPE) Certificate: For drivers with physical impairments, this certificate allows them to operate a commercial vehicle under specific conditions. It is granted when the driver has been evaluated and deemed fit to drive with the aid of prosthetics or other modifications.

These documents work together to provide a comprehensive overview of a driver's health and abilities, ensuring that safety remains a top priority in commercial driving. Proper documentation not only helps drivers meet regulatory requirements but also supports their well-being on the road.

Similar forms

  • DOT Physical Examination Report: This document serves a similar purpose as the DOT Medical form, focusing on assessing a driver's physical capabilities to operate a commercial vehicle. Both documents require a detailed health history and physical examination to ensure drivers meet safety standards.
  • Medical Examiner's Certificate: Like the DOT Medical form, this certificate confirms that a driver has passed a medical examination. It is essential for validating the driver's eligibility to operate a commercial vehicle, similar to the findings documented in the DOT Medical form.
  • Commercial Driver's License Application: This application collects information about a driver's history and qualifications. Similar to the DOT Medical form, it requires personal and health information to determine the driver's fitness for commercial driving.
  • Health History Questionnaire: This document gathers a driver's medical history, much like the health history section of the DOT Medical form. It aims to identify any potential health issues that could affect driving safety.

Dos and Don'ts

Things to Do When Filling Out the DOT Medical Form:

  • Provide accurate and complete information about your health history.
  • Sign and date the form after reviewing all sections.
  • List all medications you are currently taking, including over-the-counter drugs.
  • Discuss any health concerns with your medical examiner.
  • Wear corrective lenses during the vision test if you need them.
  • Be honest about any medical conditions, even if they seem minor.
  • Ensure your contact information is up-to-date.
  • Follow any specific instructions given by the medical examiner.
  • Prepare for the examination by getting adequate rest before your appointment.
  • Keep a copy of your completed form for your records.

Things to Avoid When Filling Out the DOT Medical Form:

  • Do not leave any sections blank; fill out everything that applies.
  • Avoid providing false or misleading information.
  • Do not forget to mention any previous medical conditions or treatments.
  • Refrain from using technical jargon that might confuse the examiner.
  • Do not ignore the importance of discussing your health history.
  • Avoid rushing through the form; take your time to ensure accuracy.
  • Do not assume that minor issues are not worth mentioning.
  • Do not forget to bring any necessary documents or identification.
  • Avoid distractions during the examination process.
  • Do not attempt to conceal any relevant health issues.

Misconceptions

  • Misconception 1: The DOT Medical form is only for new drivers.

    • This form is required for both new certifications and recertifications. Existing drivers must also complete it to maintain their medical qualifications.

  • Misconception 2: Drivers can hide medical conditions.

    • It is crucial for drivers to disclose all medical conditions. Inaccurate or missing information can invalidate the examination and the Medical Examiner's Certificate.

  • Misconception 3: Vision requirements are not strict.

    • Drivers must have at least 20/40 vision in each eye, with or without corrective lenses. This standard is essential for safety on the road.

  • Misconception 4: Hearing tests are optional.

    • Hearing is a critical component of the DOT Medical examination. Drivers must be able to perceive a forced whispered voice from at least 5 feet away, with or without a hearing aid.

  • Misconception 5: Only serious health issues affect certification.

    • Even minor conditions, if not properly managed, can impact a driver's ability to operate a commercial vehicle safely. Medical examiners consider all health history details.

  • Misconception 6: The medical examiner does not need to discuss medications.

    • Medical examiners are required to discuss any medications the driver is taking. This includes over-the-counter drugs, as they can affect driving abilities.

  • Misconception 7: The DOT Medical form is the same for all drivers.

    • Different types of drivers may face varying requirements based on their specific roles and responsibilities. The form is tailored to assess their unique fitness for duty.

  • Misconception 8: Drivers can drive with a temporary medical certificate indefinitely.

    • Temporary medical certificates are issued for limited periods, typically ranging from 3 to 12 months, depending on the driver's health status. They are not a long-term solution.

  • Misconception 9: If a driver passes the exam once, they will always pass.

    • Each examination is independent. A driver’s health can change, and they must meet the standards each time they are evaluated.

  • Misconception 10: The DOT Medical form is irrelevant for experienced drivers.

    • All drivers, regardless of experience, must complete the DOT Medical form to ensure they meet the current health and safety standards required for commercial driving.

Key takeaways

  • The DOT Medical Form is essential for commercial drivers to demonstrate their fitness to operate a commercial motor vehicle.

  • Drivers must complete their personal information accurately, including their name, Social Security number, and contact details.

  • Health history is a crucial section; drivers should disclose any medical conditions or medications that could impact their driving ability.

  • Medical examiners play a vital role by reviewing the health history with the driver and documenting any concerns regarding medications and potential hazards.

  • Vision and hearing tests are mandatory, with specific standards set for acuity and perception to ensure drivers can respond to traffic signals effectively.

  • Blood pressure and pulse rate must be recorded, as these indicators are significant for determining a driver's overall health.

  • Drivers must carry the Medical Examiner's Certificate, which validates their ability to drive, and this certificate is typically valid for two years unless otherwise noted.