Dl 51 Physical Exam Details

Dl 51 Form is a document used for the registration of businesses in India. The form must be filed with the Registrar of Companies within 30 days of commencing business operations. The Dl 51 Form is also known as the Memorandum and Articles of Association (MAA). This article will provide an overview of the Dl 51 Form, including its purpose and key components. In India, all businesses must file a Dl 51 Form with the Registrar of Companies within 30 days of commencing business operations. The form is also known as the Memorandum and Articles of Association (MAA). The MAA contains information about the company, including its name, registered address, and objects.

The listing contains specifics of the dl 51 form. It is suggested that you read this info before you begin working with the file.

QuestionAnswer
Form NameDl 51 Form
Form Length8 pages
Fillable?Yes
Fillable fields194
Avg. time to fill out20 min 26 sec
Other namesdl 51 physical exam, ca 51 form, dl 51, dl 51 dmv form

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MeDiCal eXaMination RePoRt

instRuCtions to the DRiveR

A Public Service Agency

You must use this medical examination report when applying for a Commercial California Driver License (CDL) or certiicates (School Bus,Youth Bus, SPAB, GPPV, or Farm Labor) that require a medical examination. This report also meets United States DepartmentofTransportation(DOT)requirements.A driver who does not meet DOT’s medical standards may, after evaluation by the Department of Motor Vehicles (DMV), be issued a restricted license if DMV determines the driver’s condition will not affect his or her ability to drive safely.

Drivers applying for, or who hold, a certiicate to drive a School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle must have their examination performed by a Physician Assistant, Advanced Practice Registered Nurse, Doctor of Medicine (MD), Doctor of Osteopathy (DO) or a Doctor of Chiropractic (DC) listed on the most current NationalRegistry.TheMedicalExaminationReport and Medical Certiicate must be signed by the medicalexaminerwhoperformedtheexamination.

School bus drivers 65 years of age and older must submit a new medical report to DMV every year. (Vehicle Code Section 12517.2b)

TheHealthQuestionnaire(DL546)maybeusedby drivers with a Restricted Fireighter’s License or a Non-CommercialClassCLicensewithaFireighter endorsement rather than this medical report.

The Health Questionnaire (DL 546) may also be used by drivers applying for a Non-Commercial

Class A license and those drivers who need the Agricultural Hazardous Materials or Waste Transportation Veriication of Training.

nationalReGistRyoFMeDiCaleXaMineRs BeginningMay21,2014,interstatecommercialmotor vehicledriversmusthavetheirmedicalexamination performed by a certiied medical examiner listed on theNationalRegistryofCertiiedMedicalExaminers (National Registry). A list of certiied medical examiners may be found on the National Registry Website https://nationalregistry.fmcsa.dot.gov

Class a, B, or Commercial C license

CDL drivers who have submitted a current medical examination report to DMV documenting they meet the physical qualiication requirements, no longer need to carry the medical examiner’s certiicate for more than 15 days after the date it was issued.You are required to give a medical report to DMV when you irst apply for the license and every two years thereafter. If the medical report is incomplete, your license application will be delayed or denied.

If you qualify by using a hearing aid, you must wear the hearing aid and use it whenever you are driving. Also, you must keep with you a spare power source to use in the hearing aid.

Federal Law requires that you disclose the type of commercial operation you are engaged in.

Non-Excepted Interstate:License does not restrict the transport, origination, or destination of the load to be transported.

Non-Excepted Intrastate: License is restricted to operation in California only.You may only transport cargo that originates in and the inal destination is in California. While driving commercially you may not cross state or international borders.

Excepted Interstate: California does not issue a commercial driver license that is excepted from driver qualiication requirements.

Excepted Intrastate: California does not issue a commercial driver license that is excepted from driver qualiication requirements.

Drivers renewing their medical certiicate may mail this report to:

Department of Motor Vehicles CDL Unit, G204

P. O. Box 944278

Sacramento, CA 94244-2780

If you are required to have a CDL as part of your job, your employer shall pay the cost of the examination unless it was taken before you applied for the job (Labor Code §231).

information on Drug testing

Federal regulations and state law have established minimum standards for commercial motor carriers’ antidrug programs including testing for the use of controlled substances. This testing requirement applies to drivers required to have a Commercial drivers license.

Youremployerwilltellyouwhetherornotyourmedical exam should include a drug test.

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 8-10 hours and then have 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 it. 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.

§391.41 PhysiCal QualiFiCations FoR DRiveRs

(a)(1)(i) A person subject to this part must not operate a commercial motor vehicle unless he or she is medically certiied as physically quali- ied to do so, and, except as provided in para- graph (a)(2) of this section, when on-duty has on his or her person the original, or a copy, of a current medical examiner’s certiicate that he or she is physically qualiied to drive a commercial motor vehicle.

(ii)A person who qualiies for the medical ex- aminer’s certiicate by virtue of having obtained a medical variance from FMCSA, in the form of an exemption letter or a skill performance evalu- ation certiicate must have on his or her person a copy of the variance documentation when on- duty.

(2)CDL exception. (i) Beginning January 30,

2014, a driver required to have a commercial driver’s license under part 383 of this chapter, and who submitted a current medical examiner’s certiicate to the State in accordance with § 383.71(h) of this chapter documenting that he or she meets the physical qualiication require- ments of this part, no longer needs to carry on his or her person the medical examiner’s certii- cate speciied at §391.43(h), or a copy for more than 15 days after the date it was issued as valid proof of medical certiication.

(ii)A CDL holder required by §383.71(h) to obtain a medical examiner’s certiicate, who obtained such by virtue of having obtained a

medical variance from FMCSA, must continue to have in his or her possession the original or copy of that medical variance documentation at all times when on-duty.

(3)A person is physically qualiied to drive a commercial motor vehicle if:

(i) That person meets the physical qualiica- tion standards in paragraph (b) of this section and has complied with the medical examination requirements in §391.43; or

(ii)That person obtained from FMCSA a medi- cal variance from the physical qualiication stan- dards in paragraph (b) of this section and has complied with the medical examination require- ment in §391.43.

(b)A person is physically qualiied 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) Certiicate (formerly LimbWaiver Program) pursuant to §391.49.

(2)Has no impairment of:(i)A hand or inger which interferes with prehension or power grasping; or (ii) An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or any other signiicant 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 certiicate 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 safely.

(7)Has no established medical history or clinicaldiagnosisofrheumatic,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

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(Snellen) or better with corrective lenses, distinct binocular acuity of at least 20/40 (Snellen) in both eyes with or without corrective lenses, ield of vision of at least 70 degrees in the horizontal meridian in each eye, and the ability to recognize the colors of traffic signals and devices showing standard red, green and amber.

(11)First perceives a forced whispered voice in the better ear 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 toAmerican National Standard (formerly ASA Standard) Z24.5-1951.

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

I drug or substance that is identiied in the other Schedules in 21 part 1308 except when the use is prescribed by a licensed medical practitioner, as deined in § 382.107, who is familiar with driver’s medical history and has advised the driver that the substance will not adversely affect the driver’s ability to safely operate a commercial motor vehicle.

(13)Has no current clinical diagnosis of

alcoholism.

instRuCtions to the MeDiCal eXaMineR

General information

Review these instructions before examining the driver. If you are a licensed Physician Assistant or Advanced Practice Nurse, you must be under a physician’s supervision to perform this exam. If you are a Doctor of Chiropractic you must be clinically competent to perform the medical examination. Only a Physician Assistant, Advanced Practice Registered Nurse, Doctor of Medicine (MD), Doctor of Osteopathy (DO) or a Doctor of Chiropractic (DC) listed on the most current National Registry of Certiied Medical Examiners can perform the examination for persons who will drive a School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle. The medical certiicate and medical report must be signed by the medical examiner who performs the examination.

The purpose of this examination is to determine a driver’s physical qualiication 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 qualiication 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 condition 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 it to drive and is also able to perform non-driving responsibilities as may be required, the medical examiner signs the medical certiicate which the driver must carry with his/her license, as speciied in federal regulation. The certiicate must be dated. Under current regulations, the certiicate 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 certiicate 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) 366-4001 FoR FuRtheR inFoRMation (a vision exemption, Skill Performance Evaluation [SPE] Certiicate, exempt intracity zone, qualifying drivers under 49 CFR 391.64, etc.). note: In California, if a driver is only qualiied when accompanied by a waiver/exemption, Skill Performance Evaluation Certiicate, or when qualiied by operation of 49 CFR 391.64, a copy of the waiver/exemption or certiicate must be attached to the medical report before submission to the California Department of Motor Vehicles. If the driver does not already have such a waiver/exemption or certiicate, do not check the “waiver/exemption or certiicate” boxes. If a driver does not qualify solely on the standards in 49 CFR 391.41(b) 1,2,10, or 11, he/she may be eligible for a restricted California commercial license. Please check the appropriate box on page 4.

DMV has a booklet, A Physician’s Guide for Commercial Driver License Medical Exams. This booklet contains guidelines that supplement the federal regulations. Medical examiners may request a copy of this booklet by calling (916) 657-6550. State and federal laws require this exam.

interpretation of Medical standards

Since the issuance of the regulations for physical qualiications of commercial drivers, the Federal Motor Carrier Safety Administration (FMSCA) has published recommendations called Advisory Criteria to help medical examiners in determining whether a driver meets the physical qualiications 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 speciic regulation is printed in italics and its reference by section is highlighted.

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) Certiicate pursuant to §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 inger which interferes with prehension or power grasping; or

(ii)An arm, foot, or leg which interferes with the ability to perform normal tasks associated with operating a commercial motor vehicle; or Any other signiicant 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 Skill Performance Evaluation (SPE) Certiicate pursuant to §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 (SPE) Certiication Program pursuant to §391.49, assuming the person is otherwise qualiied.

With the advancement of technology, medical aids and equipment modiications have been developed to compensate for certain disabilities. The SPE Certiication Program (formerly the Limb

Federal Motor Carrier safety Regulations

advisory Criteria

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 modiications 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 certiicates 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 qualiied (§391.41(b)(3) through (13)), the medical examiner must check on the medical certiicate that the driver is qualiied only if accompanied by a SPE certiicate. The driver and the employing motor carrier are subject to appropriate penalty if the driver operates a commercial motor vehicle in interstate or foreign commerce without a current SPE certiicate 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, semi-consciousness, 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 qualiied under the present rule. CMV drivers who do not meet the Federal diabetes standard may call (202) 366-4001 for an application for a diabetes exemption. (See Conference Report on Diabetic Disorders and Commercial Drivers and Insulin-Using Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm).

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Cardiovascular Condition: §391.41(b)(4)

A person is physically qualified to drive a commercial motor vehicle if that person:

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

The term “has no current clinical diagnosis of” is speciically 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 qualiication 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 certiied 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 conditions(s) which require treatment and the general health of the driver. The FMCSA should be contacted at (202) 366- 4001 for additional recommendations regarding the physical qualiication of drivers on coumadin. (See Cardiovascular Advisory Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers at: 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. (See Conference on Pulmonary/Respiratory Disorders

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and Commercial Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

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 the 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 certiied to drive for a one-year period. Certification examination should be done annually thereafter and should be at or less than 140/90. If less than 160/100, certiication may be extended one time for 3 months.

Ablood 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 certiication 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 certiied for one year from date of the initial exam. The driver is certiied 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 be not qualiied, even temporarily, until reduced to 140/90 or less and treatment is well tolerated.The driver may be certiied for 6 months and biannually (every 6 months) thereafter if at recheck BP is 140/90 or less.

Annual recertiication is recommended if the medical examiner does not know the severity of hypertension prior to treatment.

An elevated blood pressure inding 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 particularly undesirable in commercial drivers.

Secondary hypertension is based on the above stages. Evaluation is warranted if patient is persistently hypertensive on maximal or near- maximual doses of 2-3 pharmacologic agents. Some causes of secondary hypertension may be amenable to surgical intervention or speciic pharmacologic treatment.

(See Cardiovascular Advisory Panel Guidelines for the Medical Examination of Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

Rheumatic, arthritic, orthopedic, Muscular, neuromuscular or vascular Disease §391.41(b)(7)

A person is physically qualified to drive a commercial motor vehicle if that person:

Has no established medical history or clinical diagnosis of rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease

which interferes with the ability to control and operate a commercial motor vehicle safely.

Certain diseases are known to have acute episodes of transient muscle weakness, poor muscular coordination (ataxia), abnormal sensations (paresthesia), decreased muscular tone (hypotonia), visual disturbances and pain which may be suddenly incapacitating. With each recurring episode, these symptoms may become more pronounced and remain for longer periods of time. Other diseases have more insidious onsets and display symptoms of muscle wasting (atrophy), swelling and paresthesia which may not suddenly incapacitate a person but may restrict his/her movements and eventually interfere with the ability to safely operate a motor vehicle. In many instances these diseases are degenerative in nature or may result in deterioration of the involved area.

Once the individual has been diagnosed as having a rheumatic, arthritic, orthopedic, muscular, neuromuscular or vascular disease, then he/she has an established history of that disease. The physician, when examining an individual should consider the following: (1) the nature and severity of the individual’s condition (such as sensory loss or loss of strength); (2) the degree of limitation present (such as range of motion); (3) the likelihood of progressive limitation (not always present initially but may manifest itself over time); and (4) the likelihood of sudden incapacitation. If severe functional impairment exists, the driver does not qualify. In cases where more frequent monitoring is required, a certiicate for a shorter period of time may be issued.

(See Conference on Neurological Disorders and Commercial Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

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 qualiied: (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 certiication 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 qualiied.

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 is not taking antiseizure medication. Drivers with a history of epilepsy/ seizures off antiseizure medication and seizure- free for 10 years may be qualiied to drive a CMV in interstate commerce. Interstate drivers with a history of a single unprovoked seizure may be qualiied 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: 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 the 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 certiication for commercial driving is inadvisable. Somatic and psychosomatic complaints should be thoroughly examined when determining an individual’s overall itness to drive. Disorders of a periodically incapacitating nature, even in the early stages of development, may warrant disqualiication.

Many bus and truck drivers have documented that “nervous trouble” related to neurotic, personality, emotional or adjustment problems is responsible for a signiicant 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 lexibility 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 disqualiication. Careful consideration should be given to the side effects and interactions of medications in the overall qualification determination. See Psychiatric Conference Report for speciic recommendations on the use of these medications and potential hazards for driving.

(See Conference on Psychiatric Disorders and Commercial Drivers at:

w w w . f m c s a . d o t . g o v / r u l e s r e g s / 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, ield 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 deiciency. If certain color perception tests are administered, (such as Ishihara, Pseudoisochromatic, Yarn) and doubtful indings 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 are 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 Certiicate: “Qualiied only if wearing corrective lenses”.

CMV drivers who do not meet the Federal Vision Standard may call (202) 366-4001 for an application for a vision exemption.

(See Visual Disorders and Commercial Drivers at: w w w . f m c s a . d o t . g o v / r u l e s r e g s / 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 audiometic deviceiscalibratedtoAmericanNationalStandard (formerly ASA Standard) Z24.5-1951.

Since the prescribed standard under the FMCSRs is the American Standards Association (ANSI), it may be necessary to convert the audiometic 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 test 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 Certiicate: “Qualiied only when wearing a hearing aid”.

(See Hearing Disorders and Commercial Motor Vehicle Drivers at: www.fmcsa.dot.gov/rulesregs/medreports. htm)

Drug use §391.41(b)(12)

A person is physically qualified to drive a commercial motor vehicle if that person does not use any drug or substance identiied in 21 CFR 1308.ll, Schedule I, an amphetamine, a narcotic, or any other habit-forming drug. A driver may use a non-schedule I drug or substance that is identiied in the other Schedules in 21 part 1308 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.

This exception does not apply to methadone. The intent of the medical certiication 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 unqualiied. 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 luid testing. If body luid testing takes place, positive test results should be conirmed by a second test of greater speciicity. 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 unqualiied 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. Recertiication may involve a substance abuse evaluation, the successful completion of a drug rehabilitation program, and negative drug test result.Additionally, given that the certiication 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: 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 speciically 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 and/or treatment, he

or she may be considered for certiication.

DL 51 (REV. 1/2014) WWW FEDERAL REGULATIONS - PAGE 4

A Public Service Agency

o51

MeDiCal eXaMination RePoRt

FoR CoMMeRCial DRiveR Fitness DeteRMination

1.DRiveR inFoRMation Driver completes this section. PRint in CaPital letteRs - usinG BlaCk oR DaRk Blue ink.

 

 

 

 

 

LAST NAME

 

 

 

 

 

 

 

 

 

 

 

 

 

FIRST

 

 

 

 

DRIVER LICENSE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

CITY

STATE

 

ZIP

WORK TELEPHONE NUMBER

HOME TELEPHONE NUMBER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

(

)

 

 

 

SOCIAL SECURITY NUMBER

LICENSE CLASS

 

 

STATE OF ISSUE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A

B

C

 

 

 

 

 

 

 

New certiication

 

Recertiication

 

Follow up

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

BIRTHDATE

 

 

 

 

 

 

 

 

 

 

 

 

AGE

SEX

 

 

 

 

 

EYES

HAIR

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PLEASE READ THE “INSTRUCTIONS TO THE DRIVER” BEFORE ANSWERING.

 

 

 

 

 

 

MaRk one oF the DRivinG tyPes BeloW

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NI

Non-Excepted Interstate

 

 

 

EI

Excepted Interstate (Not available in California)

 

 

 

 

 

 

 

 

 

 

 

 

NA

Non-Excepted Intrastate

 

 

 

EA

Excepted Intrastate (Not available in California)

 

 

 

 

 

 

 

 

 

 

 

 

CheCk one oF the BoXes BeloW

I am NOT submitting this medical examination report to obtain a certiicate to operate a School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle.

I AM submitting this medical examination report to apply for or retain a certiicate to operate a School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle.

PLEASE READ THE FOLLOWING INFORMATION

If you indicated you have submitted this medical examination report for one or more of the certiicates listed above, your medical examination Must be performed by a Physician Assistant, Advanced Practice Registered Nurse, Doctor of Medicine (MD), Doctor of Osteopathy (DO), or a Doctor of Chiropractic (Chiropractor) listed on the most current National Registry of Certiied Medical Examiners. Your medical examination report and medical certiicate Must be signed by the physician who performed the examination. If your medical examination report does not indicate your medical examination was performed by an MD, DO, Physician Assistant, Advanced Practice Registered Nurse or a Chiropractor listed on the most current National Registry of Certiied Medical Examiners; DMV will not process your certiicate application or accept your medical examination report, and your medical examination report will be returned to you.

2. health histoRy Driver completes this section, but medical examiner is encouraged to discuss with driver.

yes no

Any illness or injury in last 5 years

Head/Brain injuries, disorders or illnesses

Seizures, epilepsy

medication ____________________

Eye disorders or impaired vision (except corrective lenses)

Ear disorders, loss of hearing or balance

Heart disease or heart attack, other cardiovascular condition

medication ____________________

Heart surgery (valve replacement/ bypass, angioplasty, pacemaker) High blood pressure

medication ____________________

Muscular disease

yes no

Shortness of breath

Lung disease, emphysema, asthma, chronic bronchitis

Kidney disease, dialysis

Liver disease

Digestive problems

Diabetes or elevated blood sugar controlled by:

diet

pills

insulin

Nervous or psychiatric disorders, e.g., severe depression

medication ____________________

Loss of, or altered consciousness

yes no

Fainting, dizziness

Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

Stroke or paralysis

Missing or impaired hand, arm, foot, leg, inger, toe

Spinal injury or disease

Chronic low back pain

Regular, frequent alcohol use Narcotic or habit forming drug use

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. (attach additional sheet, if needed).

I certify (or declare) under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I understand that inaccurate, false or missing information may invalidate the examination and my Medical Examiner’s Certification.

DRIVER’S SIGNATURE

DL 51 (REV. 1/2014) WWW

DATE

M M D D y y y y

Page 1 of 4

DRIVER LICENSE NUMBER

NAME

DATE OF EXAM

 

 

 

 

 

 

 

 

 

MeDiCal eXaMineR CoMPletes seCtions 3 thRouGh 8

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QualiFieD

 

not

Check each item in appropriate box to show“Qualified” or“Not Qualified”. Explain any special findings or test

QualiFieD

results NOT in an acceptable tolerance range.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. vision numerical readings must be provided

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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 Certiicate.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

 

 

 

 

 

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

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

aCuity

unCoRReCteD

 

CoRReCteD

hoRiZontal FielD oF vision

 

traffic control signals and devices showing standard

 

 

 

 

 

 

Right Eye

20/

 

20/

 

Right Eye

°

 

red, green and amber colors?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant meets visual acuity requirement only

 

 

 

 

 

 

Left Eye

20/

 

20/

 

Left Eye

 

 

°

 

 

 

 

 

 

 

 

 

 

 

 

when wearing: .................... Corrective Lenses

 

 

 

 

 

 

Both Eyes

20/

 

20/

 

 

 

 

 

 

 

 

Monocular Vision (one eye blind):

Yes

No

 

 

 

 

 

 

Complete next line only if vision testing is done by an ophthalmologist or optometrist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DATE OF EXAMINATION

(iF aPPliCaBle) NAME OF OPHTHALMOLOGIST OR OPTOMETRIST (PRINT)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TELEPHONE NO.

LICENSE NO./STATE OF ISSUE

 

 

SIGNATURE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. heaRinG numerical readings must be provided.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

standard: a) Must irst 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 500 Hz, - 10dB for

 

 

 

 

 

 

1,000 Hz, - 8.5 dB for 2,000 Hz.To average, add the readings for 3 frequencies tested and divide by 3.

 

 

 

 

 

 

 

 

 

numerical readings must be recorded.

 

 

 

 

 

RiGht eaR

 

leFt eaR

 

 

 

 

 

 

 

 

 

 

RiGht eaR

leFt eaR

 

 

 

 

 

 

 

 

500 hz

1000 hz

2000 hz

 

500 hz

1000 hz

2000 hz

 

 

 

 

 

 

a) Record distance from

 

 

 

 

 

 

 

b) If audiometer is used,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

individual at which forced

 

 

 

 

 

 

 

record hearing loss in

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

whispered voice can irst

 

 

FT.

 

 

FT.

 

decibels. (acc. to ANSI

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AVERAGE

 

 

 

AVERAGE

 

 

 

 

 

 

 

 

 

be heard.

 

 

 

 

 

 

 

 

 

Z24.5-1951)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. BlooD PRessuRe/Pulse Rate

numerical readings must be recorded. Medical examiner

 

 

 

 

 

 

 

 

 

 

 

 

 

 

should take at least two readings to conirm BP.

 

 

 

 

 

 

 

BlooD PRessuRe

 

ReaDinG

 

 

 

hyPeRtension

 

 

eXPiRation Date

 

 

ReCeRtiFiCation

 

 

 

 

 

 

SYSTOLIC

 

DIASTOLIC

 

 

 

 

 

 

 

CateGoRy

 

 

 

FoR CeRtiFiCate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

139/89 or lower with no

 

 

N/A

 

2 years

 

 

Every 2 years

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

history of Stage 1-3

 

 

 

Driver qualified

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

hypertension currently

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

requiring medication

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

140-159/90-99

 

 

 

 

Stage 1

 

1 year

 

 

1 year if 140/90 or less.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

One-time certificate

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

for 3 months if

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

141-159/91-99.

 

 

 

 

 

 

 

 

Pulse Rate

 

160-179/100-109

 

 

 

Stage 2

 

One-time certificate

 

1 year from date of

 

 

 

 

 

 

 

Regular

 

Irregular

 

 

 

 

 

 

 

 

 

 

 

for 3 months

 

 

exam if 140/90 or

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

less

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECORD PULSE RATE:

 

180/110 or higher

 

 

 

Stage 3

 

N/A Driver not

 

 

6 months from date of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

qualified

 

 

exam if 140/90

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

or less

 

 

 

 

 

 

 

 

 

6. laBoRatoRy anD otheR test FinDinGs

numerical readings must be recorded.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

urinalysis is required. Protein, blood or sugar in the urine may

 

 

 

 

 

uRine sPeCiMen

 

 

 

 

 

 

 

 

 

 

 

 

be an indication for further testing to rule out any underlying

SP. GR.

 

 

PROTEIN

BLOOD

 

 

SUGAR

 

 

 

 

 

 

 

medical problem.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

OTHER TESTING (DESCRIBE AND RECORD)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 2 of 4

DL 51 (REV. 1/2014) WWW

DRIVER LICENSE NUMBER

NAME

DATE OF EXAM

7. PhysiCal eXaMination

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. Check each item in appropriate box to show “Qualiied” or “Not Qualiied”.

As you complete items 1 - 12 below, you will ind some items that have no clearly deined measures to indicate a driver is “qualiied” or “not qualiied”. For such items, please check “qualiied” if the driver’s condition appears within normal limits.

See Instructions To The Medical Examiner for guidance.

Any abnormalities

 

present?

 

 

 

 

 

 

 

QualiFieD

not

 

BoDy systeM

CheCk FoR:

 

yes*

no

QualiFieD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.

General

Marked overweight, tremor, signs of alcoholism, problem drinking, or

 

 

 

 

 

 

Appearance

drug abuse.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

Eyes

Pupillary equality, reaction to light, accommodation, ocular motility,

 

 

 

 

 

 

 

 

ocular muscle imbalance, extraocular movement, nystagmus, exophthalmos,

 

 

 

 

 

 

 

strabismus uncorrected by corrective lenses, retinopathy, cataracts,

 

 

 

 

 

 

 

 

aphakia, glaucoma, macular degeneration.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Ears

Middle ear disease, occlusion of external canal, perforated eardrums.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Mouth and Throat

Irremediable deformities likely to interfere with breathing or swallowing.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Heart

Murmurs, extra sounds, enlarged heart, pacemaker.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Lungs and chest,

Abnormal chest wall expansion, abnormal respiratory rate, abnormal

 

 

 

 

 

 

 

not including

breath sounds including wheezes or alveolar rales, impaired respiratory

 

 

 

 

 

 

breast examination

function, dyspnea, cyanosis. Abnormal indings on physical exam may

 

 

 

 

 

 

 

 

require further testing such as pulmonary tests and/or x-ray of chest.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

Abdomen and

Enlarged liver, enlarged spleen, masses, bruits, hernia, signiicant

 

 

 

 

 

 

 

Viscera

abdominal Viscera wall muscle weakness.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Vascular system

Abnormal pulse and amplitude, carotid or arterial bruits, varicose veins.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Genito-urinary

Hernias.

 

 

 

 

 

 

 

system.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Extremities - Limb

Loss or impairment of leg, foot, toe, arm, hand, inger. Perceptible limp,

 

 

 

 

 

 

impaired. Driver

deformities, atrophy, weakness, paralysis, clubbing, edema, hypotonia.

 

 

 

 

 

 

may be subject

Insufficient grasp and prehension in upper limb to maintain steering wheel

 

 

 

 

 

 

to SPE certiicate

grip. Insufficient mobility and strength in lower limb to operate pedals

 

 

 

 

 

 

if otherwise

properly.

 

 

 

 

 

 

 

qualiied.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Spine, other

Previous surgery, deformities, limitation of motion, tenderness.

 

 

 

 

 

 

 

musculoskeletal

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12. Neurological

Impaired equilibrium, coordination or speech pattern; paresthesia

 

 

 

 

 

 

 

asymmetric deep tendon relexes, sensory or positional abnormalities,

 

 

 

 

 

 

 

abnormal patellar and Babinski’s relexes, ataxia.

 

 

 

 

 

 

 

 

 

 

 

 

 

*CoMMents

 

 

 

 

 

 

 

 

DL 51 (REV. 1/2014) WWW

Page 3 of 4

8.PhysiCian, ChiRoPRaCtoR, PhysiCian assistant, oR aDvanCeD PRaCtiCe ReGisteReD nuRse CoMPletes this seCtion

DRIVER LICENSE NUMBER

NAME

 

 

DRIVER’S IDENTITY VERIFIED BY:

DATE OF EXAM

Driver License No:

Other Photo ID (Specify ID used):

Medical examiners 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.) if the driver has previously been diagnosed with stage 1, stage 2, or stage 3 hypertension and continues to require medication for treatment of hypertension, please indicate here and follow instructions for reduced term of medical certiicate.

PhysiCian note:

A Doctor of Medicine (MD), Doctor of Osteopathy (DO), Physician Assistant, Advanced Practice Registered Nurse, or a Doctor of Chiropractic (DC) listed on the most current National Registry of Certiied Medical Examiners can perform a medical examination for persons submitting a medical examination report to operate one or more of the following: School Bus, School Pupil Activity Bus, Youth Bus, General Public Paratransit Vehicle, or Farm Labor Vehicle.

note certiication status here. See Instructions to the Medical Examiner for guidance.

PlaCe DoCtoR’s oFFiCe staMP

I certify under penalty of perjury under the laws of the State of California that I am

in this sPaCe oR

licensed, certified, and/or registered, in accordance with applicable State laws and

attaCh oFFiCe letteRheaD

regulations to perform physical examinations, that I have examined the driver named

 

above in accordance with the Motor Carrier Safety Regulations (49 CFR 391.41—391.49)

 

and with knowledge of the driving duties, I find this person:

 

(CheCk all that aPPly)

 

 

 

 

Meets standards in 49 CFR 391.41; qualiies for 2 year medical certiicate effective (must insert

 

date) _____ / _____ / _____ and which will expire (must insert date) _____ / _____ / _____.

 

 

Does not meet standards

 

 

 

 

 

May qualify for California restricted CDL if solely unqualified based on 49 CFR

 

 

 

391.41(b)1,2,10, or 11.

 

 

 

 

Meets standards, but periodic evaluation required due to _______________________

 

 

_______________________________ . Driver qualiied only for:

 

 

 

3 months

6 months

1 year

Other ______________________________

 

 

Medical certiicate effective (must insert date) _____ / _____ / _____ and will expire (must

 

 

insert date) _____ / _____ / _____.

 

 

 

Temporarily disqualiied due to (condition or medication): _______________________

 

 

Return to medical examiner’s office for follow up on ____________________________

 

only QualiFieD When:

 

 

 

 

 

Wearing corrective lenses

 

 

 

 

 

Wearing hearing aid

 

 

 

CheCk the BoXes BeloW only When the DRiveR PResents one oF the

 

DoCuMents listeD, a CoPy oF WhiCh Must Be attaCheD to this RePoRt.

 

 

 

Accompanied by a ___________________ waiver/exemption. Driver must present

 

 

exemption at time of certiication. (must attach copy)

 

 

 

Accompanied by a Skill Performance Evaluation (SPE) Certiicate (must attach copy)

 

 

 

Driving within an exempt intracity zone (not applicable in California)

 

 

 

Qualiied by operation of 49 CFR 391.64 (must attach copy of waiver/exemption)

 

A completed examination form is on file in my office.

MEDICAL EXAMINER’S NAME (PRINT)

TITLE

Physician

Chiropractor

Physician Assistant

Advanced Practice

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(

M.D.

D.O.)

 

 

 

 

Registered Nurse

 

 

 

 

 

 

ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DMV COMPLETES THIS SECTION

 

 

 

 

 

 

 

 

 

 

 

STATE MEDICAL LICENSE OR CERTIFICATE NUMBER

ISSUE STATE

 

NATIONAL REGISTRY NUMBER

REVIEWED BY (Indicate Tech ID#)

 

Field Office

HDQTRS

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAL LICENSE/CERTIFICATE ISSUE DATE

 

MEDICAL LICENSE/CERTIFICATE EXPIRATION DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Forward for further review

 

 

 

 

 

 

 

 

 

 

 

MEDICAL EXAMINER’S SIGNATURE

 

 

 

TELEPHONE NUMBER

UPDATED BY (TECH #)

 

 

DATE UPDATED

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If driver meets standards, complete a Medical Examiner’s Certiicate according to 49 CFR 391.43(h).

DATE STAMP

 

 

 

 

 

(Driver must carry certiicate when operating a commercial vehicle as speciied in federal regulation.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 4 of 4

 

DL 51 (REV. 1/2014) WWW

How to Edit Dl 51 Form

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Step 1: This webpage has an orange button that says "Get Form Now". Hit it.

Step 2: Now you are going to be on the form edit page. You can include, transform, highlight, check, cross, insert or delete fields or words.

The following sections will help make up your PDF document:

example of blanks in california dl 51

Include the requested details in the Any illness or injury in last 5, medication Eye disorders or, medication , Heart surgery (valve replacement/, medication , Muscular disease, Shortness of breath Lung disease, diet pills insulin, Nervous or psychiatric disorders, medication , Loss of, Fainting, while asleep, snoring Stroke or paralysis, and For any yes answer section.

step 2 to filling out california dl 51

In the DRIVER LICENSE NUMBER, NAME, DATE OF EXAM, MeDiCal eXaMineR CoMPletes, QualiFieD, not, QualiFieD, Check each item in appropriate box, standard: at least 20/40 acuity, INSTRUCTIONS: When other than the, numerical readings must be, aCuity unCoRReCteD CoRReCteD, Right Eye 20/, Left Eye, and Right Eye segment, describe the important particulars.

california dl 51 DRIVER LICENSE NUMBER, NAME, DATE OF EXAM, MeDiCal eXaMineR CoMPletes, QualiFieD, not, QualiFieD, Check each item in appropriate box, standard: at least 20/40 acuity, INSTRUCTIONS: When other than the, numerical readings must be, aCuity unCoRReCteD CoRReCteD, Right Eye 20/, Left Eye, and Right Eye fields to complete

Be sure to identify the rights and obligations of the parties inside the SIGNATURE X, standard: a) Must irst perceive, Check if hearing aid used for, Check if hearing aid required to, INSTRUCTIONS: To convert, numerical readings must be, RiGht eaR, leFt eaR, RiGht eaR, leFt eaR, 500 hz 1000 hz 2000 hz 500 hz 1000, a) Record distance from individual, b) If audiometer is used, AVERAGE, and AVERAGE part.

step 4 to finishing california dl 51

Prepare the template by analyzing the next areas: RECORD PULSE RATE:, 180/110 or higher, Stage 3, N/A Driver not qualified, 6 months from date of exam if, urinalysis is required, OTHER TESTING (DESCRIBE AND RECORD), PROTEIN, BLOOD, SUGAR, uRine sPeCiMen, Page 2 of 4, and DL 51 (REV.

california dl 51 RECORD PULSE RATE:, 180/110 or higher, Stage 3, N/A Driver not qualified, 6 months from date of exam if, urinalysis is required, OTHER TESTING (DESCRIBE AND RECORD), PROTEIN, BLOOD, SUGAR, uRine sPeCiMen, Page 2 of 4, and DL 51 (REV fields to insert

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